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V2 - PLANETS of ORTHODONTICS - Volume II - Diagnosis and Treatment Planning
V2 - PLANETS of ORTHODONTICS - Volume II - Diagnosis and Treatment Planning
ORTHODONTICS
Volume 2
Diagnosis and Treatment Planing
Authors:
With
This book is the sum and distillate of work that would not have been possible without the support of our families
and friends. Special thanks to the contributors who continuously provided advice in developing this book and
up-dating individual chapters.
Finally, we acknowledge the hard work and expertise of Ms Faiza Umer Hayat who was responsible for compiling
this volume.
Copyrights
All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or
by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior
written permission of Dr Mohammed Almuzian and Dr Haris Khan who have the exclusive copyright, except in
the case of brief quotations embodied in critical reviews and certain other non-commercial uses permitted by
copyright law. For permission requests, contact them at [email protected]
ISBN-13 : 979-8428271911
ASIN : B09TYM7D4Z
Preface
Questions expose our uncertainty, and uncertainty has been our motive. The authors and contributors have ag-
gregated this book, and the series of books to follow, in answer to questions covering the breadth and depths of
orthodontics. This volume covers an orthodontic examination, anchorage, space planning and variants of maloc-
clusions including sagittal, transverse, vertical and local problems. Befittingly the theme of this chapter is Mars
to represent the importance of this volume.
The writing of the book started with the amalgamation of orthodontic notes and the experience of the main two
authors, Dr Mohammed Almuzian and Dr Haris Khan. The other authors helped in proofreading, summarising
the key points in a form of the ‘exam night re-view’. There have been numerous contributors to this book, as
co-writers of specific chapters or as proofreaders, we seek to acknowledge them. To give credit where it is due,
the role of the authors and contributors of this volume are listed on the title page of each individual chapter.
Table of Contents Pitchfork analysis...................................................................19
Pancherz analysis...................................................................19
Bolton template analysis.......................................................19
Facial, smile and dental analysis.......................... 1 3D cephalometric superimpositions ..................................19
Computed tomography (C.T.)..............................................19
Facial analysis (macro-aesthetics) ...................................2 Frontal cephalometry/ posteroanterior radiographs.........21
Are CFA parameters standard?............................................2 Hand or wrist radiographs....................................................21
Importance of CFA................................................................2 Radionuclide imaging...........................................................21
Methods of CFA.....................................................................2 Requirement of digital photography ..................................21
Steps in CFA...........................................................................3 Intraoral scanning (oral scanner) ......................................22
Frontal facial analysis............................................................3 Types of intraoral imaging techniques................................22
Transverse analysis from frontal view.................................4 3D digital study models........................................................23
Aetiologies of lip incompetency .........................................5 Stereophotogrammetry.........................................................23
Profile analysis........................................................................5 Laser scanning........................................................................23
2. Analysis of the high midface............................................5 Optical surface scanning.......................................................24
3. Analysis of the maxillary area..........................................5 Structured light imaging.......................................................24
5. Analysis of the mandibular area......................................6 Magnetic resonance imaging and orthodontics................24
Smile analysis (mini-aesthetics) and its components.......6 Cephalometric In Orthodontics.......................... 31
2. Gingival Heights, Shape and Contour ......................7 History.....................................................................................32
3. Connectors..........................................................................7 Equipments.............................................................................32
5. Tooth Shade and Color.....................................................7 Clinical stages in taking a cephalogram..............................32
Imaging In Orthodontics: Radiography & Uses of cephalometry ...........................................................32
Photography......................................................... 13 Requirements of cephalometric measurement..................33
Goals of imaging....................................................................14 Common cephalometric landmarks....................................33
Classification of imaging techniques .................................14 Cephalometric lines for skeletal analysis............................33
Radiographic imaging techniques ......................................14 Cephalometric lines for dental analysis..............................34
Key aspects of IRMER 2000..................................................14 Cephalometric measurements for profile analysis............34
X-Ray variables.......................................................................14 Cephalometric measurements for lip analysis...................34
Measurements of radiation doses ......................................14 Cephalometric measurement for labionasal analysis........35
Image receptors ....................................................................16 Cephalometric measurement for labio-mental analysis...35
Setting the chair-side dental X-ray equipment..................16 Cephalometric analysis techniques.....................................35
Occlusal radiographs.............................................................16 Key cephalometric analysis ..................................................35
Periapical radiographs...........................................................16 Mills’ Eastman correction (Mills, 1970)..............................38
Bitewing radiographs.............................................................16 Limitations of the Eastman correction ..............................38
Orthopanoramic radiography (OPG).................................16 Limitations of Steiner analysis.............................................39
Lateral cephalogram..............................................................17 Space Analysis In Orthodontics........................... 43
Types of errors in cephalometric analysis...........................18 Clinical application of space analysis..................................44
Projection error......................................................................18 Advantages and disadvantages of RLSA ............................46
Maxillary skeletal and dental changes.................................19 Other Methods for Space Analysis in Permanent
Mandibular skeletal and dental changes.............................19 Dentition.................................................................................46
Template analyses ..................................................................19 Symmetry of the Arch...........................................................47
Bolton analysis........................................................................47 Helkimo Clinical Dysfunction (HCD) Index....................65
Bolton ratios, malocclusion and gender ............................48 GOSLON index......................................................................65
Bolton ratios and ethnic groups...........................................48 Tooth Wear Index..................................................................65
Exam Night Review...............................................................48 Root resorption indices ........................................................65
General advice before commencing IPR procedure ........104 Class II Division 1 malocclusion..........................................122
Long term potential side effects of IPR...............................105 Indicators for orthognathic surgery....................................122
Classification Class III malocclusion based on the The influence of the height of RME ....................................146
Treatment options for Class III malocclusion....................135 Mid-palatal suture assessment methods.............................147
Clinical implications in treating high angle.......................170 Difficulty associated with the treatment of AOB ..............188
Long term effects of pacifier and dummy sucking Management of overbite .....................................................201
Methods to reduce the unwanted labial tipping of lower Supernumerary Teeth .......................................... 228
incisors during levelling .....................................................201 Incidence of supernumerary teeth.......................................229
Advantages of segmental archwires technique ..................202 Aetiology of supernumerary teeth.......................................229
Disadvantages of segmental mechanics..............................202 Genetic influences in the development of
Effectiveness of different approaches...................................202 supernumerary teeth.............................................................229
Exam night review.................................................................203 Clinical features and effects of supernumerary teeth ......230
References.........................................................................................203 Classification of supernumerary teeth................................230
Low Angle Cases................................................... 206 Examination of supernumerary tooth................................230
Aetiology of low angle cases.................................................207 Management of supernumerary tooth................................231
Features of low angle cases...................................................207 Detailed management of each type of supernumerary ...231
Principals of treatment .........................................................207 Conical supernumerary ......................................................231
Methods to reduce overbite ................................................207 The effect of conical supernumerary on permanent
The Dahl concept...................................................................208 incisors are:............................................................................231
Exam night review.................................................................208 Tuberculate supernumerary.................................................231
These include (Becker and Chaushu, 2015):......................248 Indications for surgical removal of the palatally ectopic
Ericson and Kurol sectors’ classification as predictors of Primary Failure Of Eruptions.............................. 263
severity of impacted canine .................................................251 .............................................................................. 263
Four sector classification by Lindauer ...............................251 Classification of failure of eruption ....................................264
These include:.........................................................................251 Incidence of PFE....................................................................264
The three-sector classification by Dr Crescini...................251 Aetiology of PFE....................................................................264
Sector classification by Stivaros and Mandall ..................251 Features of PFE ......................................................................264
Alpha angle as predictors of severity of impacted canine.251 Treatment options of the PFEc.............................................264
β- and Gamma angle as predictors of severity of Aetiology of the mechanical failure of eruption ..............264
impacted canine.....................................................................251 Exam night review.................................................................265
Distance of the canine’s crown from the occlusal plane as Transposition of teeth ......................................... 267
predictors of severity of impacted canine...........................252 Types of transposition...........................................................268
Position of canine root apex anteroposteriorly as Aetiology of transposition....................................................268
predictors of severity of impacted canine...........................252 Prevalence of transposition..................................................268
Incidence of root resorption (RR) ......................................252 Classification .........................................................................268
Risk factors for resorption of lateral roots..........................252 Maxillary canine and the first premolar (Mx.C.P1) .........268
Management and treatment options for impacted Factors affecting treatment decision ..................................269
canines ...................................................................................252 These include: ........................................................................269
Indication for no active treatment.......................................253 Maxillary canine-lateral incisor transposition ..................269
Interceptive treatment...........................................................253 Maxillary canine-first molar transposition (Mx.C.M1)....269
Guidelines for interceptive extraction of deciduous Maxillary incisors transposition (Mx.I2.I1).......................269
canine......................................................................................253 Maxillary canine central incisor transposition..................269
b. Other interceptive techniques for impacted or Mandibular canine lateral incisor transposition ...............269
displayed canine ....................................................................253 Mandibular canine central incisor transposition .............269
Surgical exposure and orthodontic alignment...................254
Intraosseous migration.........................................................269
Aetiology of intraosseous migration .................................269
Clinical signs of intraosseous migration.............................269
Mupparapu classification for transmigrated mandibular ca-
nine..........................................................................................270
Exam night review.................................................................270
In this Chapter
1. Facial analysis (macro-aesthetics) 16. Connectors
2. Are CFA parameters standard? 17. Embrasures: black triangles
3. Importance of CFA 18. Method to treat black triangle
4. Unattractive features of facial appearance 19. Tooth shade and color
5. Common landmarks used in facial anthropom- 20. Teeth size and space analysis
etry diagram needed 21. EXAM NIGHT REVIEW
6. Steps in CFA
7. Frontal facial analysis
8. Transverse analysis of the frontal view
9. Profile analysis
10. Analysis of the high midface
11. Analysis of the maxillary area
12. Analysis of the mandibular area
13. Smile analysis (mini-aesthetics)
14. Dental appearance (micro-aesthetics)
15. Gingival heights, shape and contour
Facial analysis (macro-aesthetics) as unattractive:
• Little show of vermilion border
Clinical facial analysis (CFA) is a method utilised by the cli-
nician to evaluate and judge the patient ‘s face; to define its • A very high or very low smile line
proportions, volume, appearance, symmetry, and visible de- • An upper lip that slopes backward
formities (Meneghini and Biondi, 2012). Facial aesthetics is
• An everted lower lip
considered a term used to describe the quality of beauty and
acceptance. • Extreme bilabial protrusion
Are CFA parameters standard? • Lack of a well-defined labiomental fold
One of the aims of CFA is to assess the facial aesthetics of the • Severe convex or concave profile
patient. There are many factors that affect the values during
To whom CFA might be beneficial?
CFA steps, which include:
These include:
• Racial background.
• Restorative dentist.
• Cultural difference.
• Maxillofacial surgeons.
• Gender.
• Orthodontists.
• Personal preference.
• Plastic surgeons.
• Clinician philosophy.
• Ophthalmic surgeons.
Importance of CFA
• ENT surgeon.
McLaughlin and Arnett (Arnett, 2004) in their textbook ‘’Fa-
cial and Dental Planning for Orthodontist & Oral Surgeon’’ • Rehabilitative dentists.
classify the dentofacial deformities in the adult patient into
• Dermatologists.
3 groups (G):
• Non-medical professionals such as hairdressers, eye-
• G1 which can be addressed comprehensively by routine
glasses designers and make-up artists.
orthodontic treatment
When should CFA be performed?
• G2 represents a deformity with mild to moderate skel-
etal discrepancies but can be well treated by some dental Initial CFA usually starts during the observation stage, from
compensation to achieve camouflage results the time of patient entrance to the clinical practice. It can also
be performed during the questionnaire stage. The clinician
• G3 represents cases with severe facial imbalance and
should have the skill of interpreting and understanding body
malocclusion, which should be treated by combined sur-
language. However, comprehensive CFA is usually undertak-
gery and orthodontics.
en during clinical examination stage (Meneghini and Biondi,
It is inappropriate to provide the treatment modalities of G3 2012)
to G2 without making a comprehensive facial diagnosis. So,
Methods of CFA
differentiation between these two groups is considered one of
the main criteria for treatment success. The way of differenti- These include:
ating between the two groups mainly depends on the evalua- • Direct clinical examination
tion and assessment of the diagnostic records; among these is
the clinical facial analysis (CFA). • Non-radiographical imaging methods (Clinical photo-
graphs).
To sum up, the main objectives of CFA are:
• 3D photography
• To diagnose and classify the deformities especially for
borderline cases. Common Landmarks used in Facial Anthropometry
• To plan the treatment approach that addresses the pa- These include:
tient concerns and complaints. • Alar curvature (Ac): The most lateral point on the
• To predict the treatment outcomes & prognosis. curved base line of each ala, indicating the facial inser-
tion of the nasal wingbase.
Unattractive facial features
• Cheilion (Ch): The point located at each labial commis-
The following features of facial appearance are generally rated sure.
• Subtragion (Sbtr): The most anterior inferior point on There are three facial types, long, short and square face. The
the anterior inferior margin of the helix attachment to proportionate facial height to width ratio is 1.35:1 for males
the face, just above the earlobe. It is different from Porion and 1.3:1 for females (Naini and Gill, 2008).
• Superior Labrale Inferius (SLi): A landmark on the B. Vertical facial heights analysis from frontal view
lower lip located midway between Stomion Inferius and It is important to consider the vertical facial proportions and
Labrale Inferius. their balance in relation to the patient’s general build and
Steps in CFA personality. Ricketts (Ricketts, 1979) divided the face using
the middle and lower facial heights only. While Bell and Fish
These include: (Bell, 1980, Fish and Epker, 1980) divided the face into three
1. Positioning the patient in a Natural Head Position facial thirds (62-75 mm each) as below:
(NHP). NHP was developed by Moorrees (MOORREES, • Upper third, from hairline (trichion) to glabella or
1958). It is performed by asking the patient to walk into mid-brow.
the room for a few minutes to relax, then looking at a
mirror located at a distance 5 feet away, shake the head • Middle third, from glabella to subnasale,
until a comfortable position is achieved (Solow and Tall- • Lower third, from subnasale to soft tissue menton.
• Direct measurement from radiographs ARNETT, G. W. 2004. Facial and dental planning for orthodontists
and oral surgeons.
• Prediction equation and/ or table
ARNETT, G. W. & BERGMAN, R. T. 1993a. Facial keys to orth-
• Combination of radiograph and prediction equation odontic diagnosis and treatment planning--Part II. Am J Orthod
Dentofacial Orthop, 103, 395-411.
• Moyers Probability Method
ARNETT, G. W. & BERGMAN, R. T. 1993b. Facial keys to orth-
• Tanaka and Johnston Method odontic diagnosis and treatment planning. Part I. Am J Orthod
Bolton analysis Dentofacial Orthop, 103, 299-312.
ARNETT, G. W. & GUNSON, M. J. 2004. Facial planning for ortho-
• Indicates ideal proportions b/w upper & lower teeth to
dontists and oral surgeons. Am J Orthod Dentofacial Orthop, 126,
achieve adequate occlusion.
290-5.
• Etrinsic factors such as sexual dimorphism, racial and ARNETT, G. W., JELIC, J. S., KIM, J., CUMMINGS, D. R., BERESS,
ethnic variations, type of malocclusion, inclination of A., WORLEY, C. M., JR., CHUNG, B. & BERGMAN, R. 1999. Soft
anterior teeth, incisor edge thickness, and the smile arc tissue cephalometric analysis: diagnosis and treatment planning of
can affect this proportionality, usually requiring adjust- dentofacial deformity. Am J Orthod Dentofacial Orthop, 116, 239-
ments in the anterior ratio, as described by Bolton. 53.
Bolton overall ratio (BOR) with the application of the sub- BASS, N. M. 2003. Measurement of the profile angle and the aes-
sequent principle. thetic analysis of the facial profile. J Orthod, 30, 3-9.
BELL, W. H. 1980. Surgical correction of dentofacial deformities.
• BOR (Bolton overall ratio) = sum of the mandibular 12/
sum of the maxillary 12 ×100 (Mean 91.3% +1.91) BOLTON, W. A. 1958. Disharmony in tooth size and its relation to
the analysis and treatment of malocclusion. The Angle Orthod, 28,
• BAR (Bolton anterior ratio) =sum of the mandibular 6/ 113-130.
sum of the maxillary 6 × 100 (Mean 77.2%+1.65)
BURSTONE, C. J. 1958. The integumental profile. Am J Orthod 44,
1-25.
BURSTONE, C. J. 1967. Lip posture and its significance in treatment
planning. Am J Orthod, 53, 262-84.
COBOURNE, M. T. & DIBIASE, A. T. 2015. Handbook of ortho-
dontics, Elsevier Health Sciences.
COOKE, M. S. & WEI, S. H. 1988. The reproducibility of natural
head posture: a methodological study. Am J Orthod Dentofacial Or-
thop, 93, 280-8.
ENDO, T., UCHIKURA, K., ISHIDA, K., SHUNDO, I., SAKAEDA,
K. & SHIMOOKA, S. 2009. Thresholds for clinically significant
tooth-size discrepancy. Angle Orthod, 79, 740-6.
EXCELLENCE, N. I. F. C. 2000. Guidance on the extraction of wis-
dom teeth. Spiring Gardens. London: NICE.
FARKAS, L. G., HRECZKO, T. A., KOLAR, J. C. & MUNRO, I. R.
1985. Vertical and horizontal proportions of the face in young adult
North American Caucasians: revision of neoclassical canons. Plast
Reconstr Surg, 75, 328-38.
FISH, L. C. & EPKER, B. J. J. O. C. O. J. 1980. Surgical-orthodontic
cephalometric prediction tracing. 14, 36.
GONZÁLEZ-ULLOA, M. & STEVENS, E. 1968. The role of chin
correction in profileplasty. Plast Reconstr Surg, 41, 477-86.
HIXON, E. H. & OLDFATHER, R. J. T. A. O. 1958. Estimation of the
sizes of unerupted cuspid and bicuspid teeth. 28, 236-240.
JANSON, G., BRANCO, N. C., FERNANDES, T. M., SATHLER, R.,
GARIB, D. & LAURIS, J. R. 2011. Influence of orthodontic treat-
ment, midline position, buccal corridor and smile arc on smile at-
In this Chapter
1. Goals of imaging 17. Bolton template analysis
2. Classification of imaging techniques 18. 3D cephalometric superimpositions
3. Radiographic imaging techniques 19. Computed tomography (C.T.)
4. Essential legal requirements of IRMER 2000 20. Cone Beam Computerized Tomography (CBCT)
5. X-Ray variables 21. Frontal cephalometry/ posteroanterior view
6. Measurements of radiation doses 22. Radionuclide imaging
7. Digital radiography 23. Non-ionizing imaging techniques
8. Image receptors – film and digital 24. 3D digital study models
9. Periapical radiographs 25. Stereo photogrammetry
10. Bitewing radiographs 26. Laser scanning
11. Orthopanoramic radiography (OPG) 27. Structured light imaging
12. Lateral cephalogram 28. EXAM NIGHT REVIEW
13. Projection error
14. Template analyses
15. Pitchfork analysis
16. Pancherz analysis
Isomething
maging is the process of making a visual representation of
Key aspects of IRMER 2000
The main aspects are:
(the creation of an image).
Goals of imaging • Justification must be based on the aim of exposure,
potential benefits, risks,diagnostic needs, the efficacy,
These include: benefits and risks of alternative techniques.
• Obtaining an image of the region of interest (Graber et • Optimization: This refers to reducing the ionizing dose
al., 2016). as low as reasonably practicable (ALARP) by increasing
• Viewing the area of interest in at least two planes at the KV, using digital film, fast speed film, collimator,
right angles to each other. film holder, staff training and regular quality assurance.
• Obtaining images with maximum detail, minimal dis- • Pregnant staff should not receive more than 1 mSv of
tortion, and minimal superimposition, radiation to the abdomen, and should consult radiation
protection advisor if taking more than 150 radiographs
Classification of imaging techniques per week.
There are two main types of imaging techniques, two and • 2 meter distance should be maintained from the pri-
three-dimensional images. Conventional radiographs are mary X-ray beam to operating staff.
two-dimensional images of a three-dimensional objects,
while three-dimensional imaging reflects the true form of • Lead aprons are no longer justified for routine use
the object under consideration in a 1:1 image to size ratio. in dental photography and its use during panoramic
There are several types of imaging techniques such as ra- radiography is positively discouraged. (Guidelines on
diography, clinical photography, digital, video, and optical. Radiology Standards in Primary Dental Care. NRPB/
Imaging techniques can be also categorised into ionizing RCR Working Party 1994)
and non-ionising imaging techniques. • Finally, there is no requirement of routine thyroid collar
Radiographic imaging techniques use.
• Genetic stochastic (random) effects are shown in DSLR (digital single-lens reflex) cameras are highly recom-
offspring of recipient. For orthodontic radiography, it is mended for taking orthodontic photographic records. DSLR
important to reduce radiation to skin, bone, bone mar- camera consists of (Hutchinson and Williams, 1999, Lozano,
row, thyroid, and salivary glands, especially in children 2015, Kalpana et al., 2018):
(Thorne, 1992). Children have higher risk from ionizing • Camera body (minimum of 4-5 Mega Pixels is re-
radiation for two reasons: firstly, due to the higher cell quired),
and tissue sensitivity to radiation than adults, secondly
due to the longer lifespan than adults in which radia- • Macro lenses (Fixed focal length of 85-105 mm, 1:2.8
tion-induced changes may manifest. Therefore, exami- Ultra Sonic Motor and Adjustable manual focus)
nation of children need to be performed carefully and • Memory card,
In this Chapter
1. History
2. Equipments
3. Clinical stages in taking a cephalogram
4. Uses of cephalometry
5. Requirements of cephalometric measurement
6. Common cephalometric landmarks
7. Cephalometric lines for skeletal analysis
8. Cephalometric lines for dental analysis
9. Cephalometric measurement for profile analysis
10. Cephalometric analysis techniques
11. Key cephalometric analysis
12. EXAM NIGHT REVIEW
T he term cephalometric came from Latin meaning ‘mea-
ing the head to tip down) and respiratory pattern (in order
to increase airway patency patients may tip their head up).
surement of the head’. The conventional meaning of cepha- There are two methods of attaining NHP:
lometric is ‘using a standardised skull radiograph to assess
facial, dental, skeletal relationships and airway analysis. 1. Crude method: Patient is relaxed and looks at a distant
Cephalometric is a 2 dimensional image of a 3 dimensional object on the horizon.
object. Cephalometric evaluation is integral to orthodontics 2. Sensory method: Patient looks at their own eyes in a
and used for assessment, diagnosis and treatment planning mirror, and moves their head up and down in increas-
of the orthodontic patient. ingly smaller movements until they feel they are in a
History comfortable position.
Cephalometric machine was developed in the 1930’s by Sometimes the Frankfort plane is used to help orientate the
Broadbent (USA) and Hofrath (Germany) and used for patient in NHP, by keeping the Frankfort plane parallel to
growth studies (Broadbent, 1937). Originally postero-ante- the floor. However, the Frankfort plane is an anatomical
rior and lateral views were recommended to allow 3-dimen- position and therefore might not be reproducible for the
sional assessment (Broadbent, 1937). patient.
• Cephalostat or craniostat: It is used to position the 1. Diagnosis and treatment planning including:
patient’s head in the machine, hence, it is a stabilizing • Assessment of sagittal and vertical skeletal relation-
apparatus with ear rods. It also contains the cassette ships.
holder and film.
• Assessment of incisor inclination and position.
• Cassette: It usually contains rare earth intensifying
• Assessment of soft tissue profile.
screens and indirect action film. The dimension is usu-
ally 18 x 24 cm. It is placed 45 to 55 cm (1.5 to 1.8 feet) • Orthognathic surgery planning and VTO (visual
behind the mid-sagittal plane of the patient. The greater treatment objectives).
the distance from the mid-sagittal plane, the greater the
• Helping in detection and localization of unerupted
magnification error.
teeth or pathology.
• X-ray generating apparatus: The x-ray source is in a
2. During active treatment including:
fixed position relative to the cephalostat and the film.
Therefore, successive radiographs are standardized and • Assessment of skeletal and dental relationships post-
can be compared by superimpostion without magnifi- functional therapy.
cation error. The x-ray source should be 120-150cm (5
• Assessment of incisor position, to plan mechanics of
feet) away from the mid-sagittal plane of the patient.
space closure and anchorage demands.
Collimation of the x-rays occurs through the use of a
triangular collimator. This limits exposure to the pa- • In orthognathic surgery cases for surgical planning,
tient’s cranial base and facial skeleton. as well as post-operatively to assess surgical changes.
• Aluminum wedge filter: It has a specific design in 3. End of treatment including:
order to attenuate the x-ray beam selectively in the • Assessment of dental arch relationship.
soft tissue region. The wedge filter enhances soft tissue
visibility on the film. The wedge filter is either attached • Planning retention according to treatment changes.
to the tube head or the cepalostat, hence, positioned • Baseline records to monitor changes in post-reten-
between the patient and the anterior part of the cassette. tion phase (Björk, 1954).
Clinical stages in taking a cephalogram • Determining the reasons for relapse and unfavour-
The patient is positioned in the cephalostat in natural head able growth, especially in orthognathic surgery cas-
position (NHP). NHP is a physiological and reproduc- es.
ible position, in which the patient usually positions their 4. Research purposes (Bjork and Palling, 1955, Bjork, 1955)
head. NHP can be reproduced within 1 or 2 degrees. NHP
is affected by audio-visual reflex, skeletal pattern (in Class Is lateral cephalometry essential for treatment planning?
II cases the patients may tip their head up), growth pattern This is a very debatable topic in which the clinician skills
(posterior rotation can result in the mandible flexing caus-
32 Cephalometric In Orthodontics
and philosophy have significant impact. Generally, the use of • Menton (Me): The most inferior point of the mandibu-
cephalograms depends on the clinician’s experience, prefer- lar symphysis in the midline, while soft tissue Menton
ences and the severity of cases. (Me’) is the lowest point on the contour of the soft tissue
chin.
It was concluded in one study that only 4-20 % of treatment
plans could have changed in the presence of cephalometric • Gonion (Go): The most posterior and inferior point on
analysis (Bruks et al., 1999). Another study showed that the angle of the mandible.
cephalometric analysis is not an essential requirement for
• Pogonion (Pog): The most anterior point on the bony
orthodontic treatment planning, as it did not influence treat-
chin, while soft tissue Pogonion (Pog’) is the most
ment planning decisions for patients with Class II malocclu-
prominent point on the soft tissue chin.
sions (Nijkamp et al., 2008).
• Point A (subspinale): This is the deepest point on the
Requirements of cephalometric measurement
curved contour of the bony maxilla between the ante-
These include: rior nasal spine and alveolar crest.
• Reliable. • Point B (supramentale): This is the deepest point on the
curved contour of the mandible between the chin and
• Reproducible.
alveolar crest.
• Accurate.
• Molar superioris (Ms): The mesial cusp tip of the upper
• Easy. first molar.
• Accessible and cheap. • Molar inferioris (Mi): The mesial cusp tip of the lower
first molar.
• Use of stable reference points.
• Incisor superius (Is): Tip of the crown of the most ante-
• Not be affected by patient size or age.
rior upper central incisor.
Common cephalometric landmarks
• Upper incisor apex (Banerjee et al.): The root apex of
These include: the most anterior upper central incisor.
• Sella (S): Midpoint of the sella turcica (pituitary fossa). • Incisor inferius (Guyer et al.): Tip of the crown of the
• Porion (Po): Most posterior and superior point on the most anterior lower central incisor.
external auditory meatus. • Lower incisor apex (LIA): The root apex of the most
• Condylion (Cd): The most posterior and superior point anterior lower central incisor.
on the mandibular condyle. • Glabella (G): Mid-brow area, and taken as the most
• Nasion (N): The most anterior point on the frontonasal prominent point on the forehead in the mid-sagittal
suture in the midline, while soft tissue Nasion (Van plane.
Leeuwen et al.) is the most prominent point on the soft • Pronasale (P): The most prominent anterior part of the
tissue in front of Nasion point. nose tip.
• Anterior nasal spine (ANS): The tip of the anterior nasal • Subnasale (Sn): Junction between the beginning of the
spine in the midline. upper lip and lower border of the nose in the mid-
• Posterior nasal spine (PNS): The tip of the posterior sagittal plane.
nasal spine in the midline. • Labrale superius (LS): The most prominent point on
• Articulare point (Ar): Point on intersection of poste- the maximum convexity of the vermillion border of the
rior cranial base and posterior border of the ascending upper lip in the mid-sagittal plane.
ramus. • Labrale inferius (LI): The most prominent point at the
• Basion (Ba): The most anterior inferior point of the maximum convexity of the vermillion border of the
foramen magnum. lower lip in the mid-sagittal plane.
• Orbitale (Or): The most inferior and anterior point on Cephalometric lines for skeletal analysis
the orbital margin. These include:
• Gnathion (Gn): The most anterior and inferior point on • Frankfort horizontal line / plane: A line constructed
the bony chin. from porion to orbitale. Another way to construct the
Frankfort line is simply to draw it at a specific inclina-
Cephalometric In Orthodontics 33
tion to SN, usually 6 degrees. The inclination of SN to point of the overlap of the mesio-buccal cusps of the
the true horizontal plane (or to the Frankfort plane first molars and the buccal cusps of the premolars or
if true horizontal plane is not known) should always deciduous molars. It is used by Ricketts (Ricketts, 1960,
be noted, and if the inclination of SN is more than 8 Ricketts, 1961) and in the Wits analysis (Jacobson,
degrees, any measurements based on SN should be 1975).
corrected by this difference. The drawbacks in using of
• Bisecting occlusal plane/ line: A line joining the mid-
Frankfort horizontal line include that both porion and
point of the overlap of the mesio-buccal cusps of the
orbitale are bilateral structures which frequently do not
upper and lower first molars with the point bisecting
coincide and therefore have to be averaged. They are
the overbite of the incisors. It is used by Downs (Downs,
also difficult to locate in some cases.
1948, Downs, 1952) and Steiner (Steiner, 1953).
• Sella-nasion line / plane: The line is constructed from
Cephalometric measurements for profile analysis
sella to nasion, and represents the anterior cranial base.
The benefits of Sella-Nasion line are the ease to locate These include:
both Sella and Nasion points lie in the midsagittal
• Soft tissue Nasion to Frankfort horizontal plane: By
plane. Sella-nasion line is useful in assessing the vertical
using this technique a vertical line is drawn from soft
jaw relationship, correction of the Frankfurt plane, in
tissue Nasion perpendicular to Frankfort horizontal.
evaluating the inclination of upper incisors to the cra-
Subnasale or soft tissue point A should be approxi-
nial base and it can be used as a stable reference point
mately 2-3 mm in front of this line, and the soft tissue
on the cranial base for superimposition. The weaknesses
Pogonion should lie 2 mm behind this facial plane.
of Sella-Nasion line include that the Sella point can alter
during early growth and that the Nasion can be sub- • Facial vertical or Meridian line was developed by
jected to both horizontal and vertical growth changes/ Gonzales-Ulloa (Gonzalez-Ulloa, 1962, González-Ulloa
variations. and Stevens, 1968), by dropping a line from soft tissue
Nasion, perpendicular to true horizontal line with the
• Maxillary line / plane: It is a line connecting the anterior
patient in natural head position. Subnasale should lie on
nasal spine and the posterior nasal spine. The Maxillary
this line while soft tissue pogonion should be 0 ± 2 mm
line is used to assess the relationship between Maxilla to
to this line.
Frankfort plane, to SN plane, to mandible as well as the
inclination of upper incisors to the maxillary skeletal • Bass aesthetic analysis (Bass, 2003): In this analysis a
base. The line can be used for maxillary superimposi- perpendicular line is dropped from Subnasale with the
tion. patient in NHP.
• Mandibular line / plane: It can be constructed (a) as a • Z angle (Merrifield, 1966): It is formed by the intersec-
line tangent to the lower border of the mandible and tion of the tangent to the chin and vermilion border of
Menton, as described by Tweed (Tweed, 1946, Tweed, most prominent lip and Frankfurt horizontal, normal
1954), Wylie (Wylie, 1947) and Ricketts (Ricketts, 1960, value range is at 80˚+9˚. It is also called the “Profile line
Ricketts, 1961). Other described it as a line connecting of Merrifield”.
Gonion to Gnathion, as described by Steiner (Steiner, • Profile angle is the angle of convexity as described by
1953) or as as a line connecting Gonion to Menton, as Burstone. This angle formed between a line from soft
described in the Eastman analysis (Mills, 1970). tissue glabella to subnasale, and from subnasale to soft
• The Mandibular line is used to assess the relationship tissue pogonion. It represents the total facial angle and
between vertical jaw relationship, mandibular to Frank- range from 165˚ -175˚.
fort plane, to SN plane, to maxillary line as well as the • Powell analysis involves a combination of nasofrontal
inclination of lower incisors to mandibular plane. It can angle, nasofacial angle, nasomental angle, and mento-
be also used for mandibular superimposition. cervical angle. It has been developed to give insight into
Cephalometric lines for dental analysis an ideal facial profile.
These include: Cephalometric measurements for lip analysis
• Anatomical occlusal plane connecting the tip of lower These include:
incisor edges to the midpoint between the upper and • Esthetic line (E-line) (Ricketts): It connects the nasal tip
lower first permanent molar cusps. It is used in the (pronasale) to soft tissue pogonion. In adults, the upper
Bjork analysis (Bjork, 1947, Björk, 1954). lip should be 4mm behind this line while the lower lip
• Functional occlusal plane is the line joining the mid- should be 2 mm behind this line. The assessment of
lips using the E line is dependent on the nose and chin
34 Cephalometric In Orthodontics
projection. 2. Designed for treatment planning such as Ballard con-
version technique
• Steiner line (S-line): It connects soft tissue pogonion to
the midpoint between subnasale and the nasal tip. The 3. Analysis of change in growth and treatment such as
lips should touch this line.
• Pancherz technique
• Harmony line (H-angle): The H-angle is formed by a
• Pitchfork technique
line tangent to the chin and upper lip with the NB line.
Holdaway stated that in balanaced, H-angle should be • Bolton (Template analysis)
within the range of 7° to 15°, which is dictated by the
4. Research purposes such as Bjork technique
patient’s skeletal convex¬ity. The ideal position of the
lower lip to the H line is 0 to 0.5 mm anterior. Ideally Key cephalometric analysis
this line should bisect the nose. 1. Sagittal analysis such as:
Cephalometric measurement for labionasal analysis • SNA: The anteroposterior position of the maxilla is as-
Nasolabial angle (NLA) is formed between the nasal colu- sessed by measuring the angle formed between the lines
mella and the upper lip. The average value is 90˚–110˚. It SN and NA.
can be divided by true horizontal at subnasale point into • SNB: The anteroposterior position of the mandible is as-
two angles (upper one represents the nasal angulation of an sessed by measuring the angle formed between the lines
average 28˚, and the lower angle represents the upper lip SN and NB.
angulation of average 85 ˚). NLA depends on:
• ANB: The difference between SNA and SNB angles de-
• Anteroposterior position of upper incisors. fines the anteroposterior relationship between the max-
• Anteroposterior position of the maxilla. illa and mandible.
• The morphology of the upper lip. • However, it is important to notice that both points A and
B do not represent the true anterior extent of the skeletal
• The vertical position of the nasal tip.
bases.
• Columella position and orientation.
Factors affecting the ANB angle
Cephalometric measurement for labio-mental analysis
These include:
Labiomental angle is the angle formed between the lines
• Cranial base length.
from lower lip to soft tissue B point, and soft tissue B point
to soft tissue Menton. It is influenced by the incisor inclina- • Cranial base orientation.
tion and anterior lower face height. The average value is • A and B points can be changed due to bone remodelling
110–130 degree. Excessively proclined lower incisor teeth, that occurs during the orthodontic movement of the
a prominent chin and a reduced lower anterior facial height upper and lower incisor teeth.
may lead to an acute labiomental angle.
• Jaw orientation.
Cephalometric analysis techniques
• Facial height.
They can be classified into analysis that:
Ballard cephalometric analysis
1. Solely describe disharmony such as
This analysis is used to assess the anteroposterior jaw posi-
• Down’s technique tion through measuring the cephalometric overjet (Ballard,
• Steiner technique 1951). The inclination of the incisors is decompensated to
the normal values, and then the overjet is measured. The
• Ricketts technique
normal value of the upper incisor to the maxillary plane is
• Harvold technique 109˚, and the lower incisor to the mandibular plane is 93˚.
But for Ballard conversion, the value of the lower incisors is
• McNamara technique
calculated by subtracting the maxillary–mandibular plane
• Sassouni technique angle (MMPA) from 120°. In order to perform Ballard
conversion: (a) Trace on a separate piece of tracing paper the
• Wits technique
outline of the maxilla, the mandibular symphysis, the inci-
• Wylie technique sors and the maxillary and mandibular planes, (b) mark the
‘rotation points’ of the incisors one-third of the root length
• Tweed technique
away from the root apex, (c) by rotating around the point
Cephalometric In Orthodontics 35
marked, reposition the upper incisor at an angle of 109° to onto the functional occlusal plane (AO and BO), where the
the maxillary plane and repeat the same for the lower inci- horizontal difference between these points is subsequently
sor taking in consideration the adjusted value based on the measured. The Wits analysis is influenced by tooth position
MMPA value. and movement as point A and B are subject to remodelling
depending on incisor position. This can affect the horizonal
Interpretations of Ballard conversion
and vertical position of A and B points. The weakness of
These include: the Wits appraisal is the difficulty to construct the occlusal
plane which significantly affect the outcome measurement.
• Mild skeletal 2: Lower incisors occlude behind the
If there is a clockwise rotation of the occlusal plane, AO will
cingulum plateau but not posterior to the upper incisor
be behind BO. If there is a counter clockwise rotation of the
tooth.
occlusal plane, BO will be ahead of AO, and not represent
• Severe skeletal 2: Lower incisors occlude behind the cin- the anteroposterior discrepancy. Some important points of
gulum plateau and posterior to the upper incisor tooth. the Wits appraisal is given in table 1.
• Mild skeletal 3: Lower incisors occlude anterior to up- Table1: Wits analysis Jacobson (1975)
per cingulum plateau and positive overjet.
Males BO should lie 1mm ahead
• Severe skeletal 3: Lower incisors occlude anterior to up-
of AO
per cingulum plateau and reverse overjet.
Females AO should coincide with
Weaknesses of Ballard conversion BO
It relies on the basis that upper and lower incisors have an Skeletal Class II malocclu- AO should lie ahead of BO
average inclination to the cranial base. It also relies on the sion
fact that the centre of resistance being one third from the Skeletal Class III malocclu- BO lies ahead of AO
apex, and incisors rotate around this point, which is not true sion
in all cases
Harvold Analysis
Sassouni analysis
It describes the severity and degree of jaw disharmony by
This analysis uses five horizontal anatomic planes: measuring the unit lengths of the mandible (Condylion-
• The inclination of the anterior cranial base. Pog) and the maxilla (Condylion-ANS), and comparing the
difference between them (Table 2) (Harvold, 1974). The dif-
• Frankfort plane. ference between these numbers provides an indication of the
• Palatal plane. size discrepancy between the jaws. The vertical assessment is
made via ANS-Me. It must be kept in mind that the shorter
• Occlusal plane.
the vertical distance between the maxilla and mandible, the
• Mandibular plane. more anteriorly the chin will be placed for any given unit
difference, and vice versa
Sassouni evaluated the anteroposterior position of the face
and dentition by using the above planes and constructing Downs analysis
various arcs intersecting them.
It is one of the earliest analyses which comprised of both
Interpretation of Sassouni analysis skeletal and dental components in the presence of normal
occlusion .Frankfort plane is used as a reference. Downs
These include:
study (Downs, 1948, Downs, 1952, Downs, 1956) was based
• Well-proportioned faces: The planes converge towards a on 20 Caucasian boys and girls, aged 12-17 years with excel-
single point and the anterior nasal spine, the maxillary lent facial and occlusal balance (Table 3 & 4).
incisor, and the bony chin should be located along the
same arc.
• Short face: If the planes intersect posterior to the occipi-
tal bone it means the patient has a short face / skeletal
deep bite).
Wits analysis by Jacobson The Wits analysis was conceived
primarily as a way to overcome the limitations of ANB as
an indicator of jaw discrepancy. (Jacobson, 1975, Jacobson,
1976). It is based on the vertical projection of points A and B
36 Cephalometric In Orthodontics
Table 2: Harvold Analysis
Variables Purpose Male Female
Maxillary length Measure the distance from the anterior bor- Mean values with age Mean values with age
der of the mandibular condyle to the anterior
nasal spine Age mm Age mm
6 82 6 80
9 87 9 85
12 92 12 90
14 96 14 92
16 100 16 93
Mandibular length Measure the distance from the same point to Age mm Age mm
the anterior point of the chin (Pog)
6 99 6 97
9 107 9 105
12 114 12 113
14 121 14 117
16 127 16 119
Lower face height Measure the distance from the Anterior nasal Age mm Age mm
spine to Menton
6 59 6 57
9 62 9 60
12 64 12 62
14 68 14 64
16 71 16 65
Cephalometric In Orthodontics 37
Table 4. Downs analysis dental component
38 Cephalometric In Orthodontics
Skeletal analysis the mandible to cranial base is assessed using a vertical
line extending downward from Nasion perpendicular to
SNA 82° the Frankfort plane. The mandible (point Pog) should
SNB 80° be slightly back of this line (–2 to –4 mm).
ANB 2° • Anteroposterior skeletal base relationships unit mea-
SN-Mandibular plane 32° surements including: maxilla length unit measured
Condyle to E point 25° ±4 from Co–A point, mandibular length unit measured
from Co–Gn and the difference between these numbers
Pog-L point 66° ±4
provides an indication of the size discrepancy between
SN-Occlusal line 14.5° the skeletal bases.
Dental analysis • Vertical skeletal assessment including lower face height
Upper first molar to NA 27mm (ANS-Me), FMPA (Adults 22° while mixed dentition
IMPA 93° 25°)and facial axis (90°).
Inter incisal angle 130° • Dental relationships including upper incisor (the facial
Lower first molar to NB 23 mm surface of the upper incisor is assessed relative to a per-
pendicular line through point A, the average is 4-6mm)
U.I-NA distance 4mm
and lower incisor (the facial surface of the lower incisor
U.I-NA angle 22° is assessed relative to the A-Pogonion line, as in the
L.I-NB distance 4mm Ricketts analysis).
L.I-NB angle 25° • Airway space including upper pharyngeal width (<5
Steiner also pointed out acceptable compromises in ANB mm) and lower pharyngeal width (10–12 mm).
angle which he called Steiner sticks or chevrons. Tweed analysis
Limitations of Steiner analysis It was introduced by C. H. Tweed in 1946. It establishes the
These include (Abdullah et al., 2006): prognosis of treatment on the basis of the Tweed triangle,
which is formed by the FMPA and lower incisor axis planes
• It is difficult to rely on the ANB angle as it is influenced (Tweed, 1946, Tweed, 1954). A Frankfort mandibular inci-
by the vertical height of the face. If the vertical distances sor angle (FMIA) of 65-70° is considered ideal for good
between Nasion and points A and B increased, the ANB aesthetic outcomes. The lower incisor angle is adjusted to
angle decrease and vice versa. achieve the ideal FMIA and treatment is planned to achieve
• If the anteroposterior position of Nasion is abnormal, it this. The analysis has been used as a total analysis by some,
will change ANB value. One of the reasons for the birth even though Tweed stressed it was intended only as a treat-
of Wits analysis was to overcome this drawback. ment aid. The validity of the total analysis of Tweed triangle
has not been proven.
Ricketts analysis
2. Bjork analysis
It is a profile orientated analysis. It includes an aesthetic
plane and other variables similar to Downs’ analysis (Rick- This analysis involves over 90 measurements and it is re-
etts, 1960, Ricketts, 1961) . search orientated (Bjork, 1947, Björk, 1954). The analysis is
based on the polygon N-S-Ar-Go-Gn using the three angles:
McNamara analysis Saddle angle (N-S-Ar), Articular angle (S-Ar-Go) and Go-
The McNamara analysis combines elements of previous nial angle (Ar-Go-Gn), and the linear measurements of the
analyses (Ricketts and Harvold). Both Frankfort plane and sides of the polygon. The analysis also assesses the anterior
Basion-Nasion lines are used as reference planes (McNama- and posterior face height relationship ratio (PFH : AFH).
ra, 1984). This analysis evaluates the position of the denti- 3. Bolton template analysis
tion and jaws relative to each other, and to the cranial base.
The McNamara analysis includes: The templates exist in two forms:
• Anteroposterior skeletal base relationships relative • Schematic templates: showing the changing position of
to the cranial base: The relationship of the maxilla to selected landmarks with age on a single template.
cranial base can be assessed a vertical line extend- • Anatomical complete templates:This is particularly con-
ing downwards from Nasion, perpendicular to the venient for direct visual comparison of a patient with
Frankfort plane. The maxilla (point A) should be on or the reference group, whilst accounting for age.
slightly ahead of this line (0-1 mm). The relationship of
Cephalometric In Orthodontics 39
4. Pi analysis (Kumar et al., 2012) Exam Night Review
The Pi analysis has been introduced as a new method to CEPHALOMETRICS
assess the AP jaw relationship. It consists of two variables:
• Term cephalometric comes from Latin and the literally
the Pi angle and the Pi linear measurement. It utilizes the
meaning ‘measurement of head’
skeletal landmarks G and M points to represent the mandi-
ble and maxilla respectively. The advantage of these points is • Cephalometrics ( branch of orthodontics) used for
they are not affected by local remodelling secondary to den- assessment, diagnosis and treatment planning of the
tal movements, unlike points A and B. The reference plane orthodontic patient.
utilized in measuring the Pi analysis is the true horizontal,
• Developed in 1930’s by Broadbent (USA) and Hofrath
a line perpendicular to the true vertical obtained in natural
(Germany)
head position (NHP). The mean values for the Pi angle are:
Equipment
• Skeletal Class I: 3.40 (+2.04).
• Cephalostat or craniostat
• Skeletal Class II: 8.94 (+3.16).
• Cassette
• Skeletal Class III: 23.57 (+1.61).
• X-raapparatus
5. Pancherz analysis (Pancherz, 1982)
• Aluminum wedge filter
This analysis measures skeletal and dental treatment changes
of the mandible and maxilla by measuring linear changes Clinical stages in taking a cephalogram.
from a perpendicular plane at Sella to the occlusal line with Patient is positioned in the cephalostat in natural head posi-
radiographs superimposed on the SN plane. The weakness tion (NHP).
of this method is that it depends on maxillary structures and
the occlusal plane (OP), which are subject to change with NHP is a physiological and reproducible within 1 or 2 de-
dento-alveolar movements. grees. There are two methods of attaining NHP:
6. Pitchfork analysis (Johnston, 1996) • Crude: Patient is relaxed and looks at a distant object
in the horizon.
This analysis involves superimposition of 2 or more lateral
cephalograms to measure dental and skeletal changes rela- • Sensory: Patient looks at their own eyes in a mirror
tive to the functional occlusal plane (OP). Dental changes NHP is affected by:
are measured relative to the basal bone of the jaws while
skeletal changes are measured relative to the anterior cranial • Audio-visual reflex.
base. • Skeletal pattern
• Growth pattern
• Respiratory pattern
Uses of cephalometry
• Diagnosis and treatment planning before com-
mencing treatment
• During active orthodontic treatment
• End or near end of treatment
• Research purposes
40 Cephalometric In Orthodontics
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Cephalometric In Orthodontics 41
42 Space Analysis In Orthodontics
4
Space Analysis In
Orthodontics
Written by: Mohammed Almuzian, Haris Khan, Ayesha Tariq, Hajira Arham, Amna Sabeeh Noor
In this Chapter
1. Clinical application of space analysis.
2. Basic terminologies in space analysis
3. Permanent dentition space analysis
4. Advantages and disadvantages of RLSA
5. Mixed Dentition Space Analysis
6. Symmetry of the arch
7. Bolton analysis
8. Bolton ratios, malocclusion and gender
9. EXAM NIGHT REVIEW
Sdeficient
pace analysis is the process of calculation of excess or
widths of each tooth measured using vernier caliper or
dividers.
space in both arches for correcting a malocclusion
(Proffit et al., 2012). 3. Discrepancy between the space available and required is
the quantified crowding or spacing in the arch. A posi-
Clinical application of space analysis tive sign is given for spacing and a negative sign is given
These include: for crowding.
Arch width intercanine: Distance between the canine cusp • Tooth inclination
tip to the cusp tip of the contralateral canine The first four elements affect space requirements significant-
Arch Depth or Arch length:The distance from a line per- ly while others contribute minimally.
pendicular to the line connecting the mesial surfaces of the Spacing and Crowding analysis include all teeth up to mesial
permanent first molars to the midpoint of central incisors. surface of 1st molars. The recommended method involves
Sometimes widest point of molars is used instead of mesial using a transparent ruler over the occlusal of maligned teeth
surface. parallel to the floor and as close as possible to the arch form
Arch expansion: Widening of the dental arch. that represent the majority of the teeth to measure the space
available. The total mesiodistal width of each individual
Arch lengthening: Increase of arch length by posterior tooth is measured, the sum of the individual tooth size is
teeth distalization or anterior proclination. subtracted from the arch perimeter to calculate the space
Study model analysis to assess space requirements surplus or deficiency. Crowding of two adjacent teeth can
also be assessed by measuring the mesiodistal widths of two
Study model analysis is either undertaken manually or with teeth and comparing it to the combined space available over
the aid of a computer (Schirmer and Wiltshire, 1997) and it the arch, however, this should not be performed on three
includes three measurements: or more teeth as the discrepancy between chord and arc
1. Arch perimeter / space available assessment increases. Chord is the distance measured in a straight line
and arc being the curvature of archform. Incisor that repre-
• Segmental technique: The arch is divided into four sent the archform should also be included in cephalometric
segments: two anterior segment; right and left (1-3), analysis and overjet measurement to avoid double counting.
and two posterior segment (3-6). A linear measure-
ment is made from 2 points of each segment. Leveling of the curve of Spee (COS): COS represents the line
passing through the buccal cusps and the incisal edges from
• Stainless steel (SS) / brass wire technique: A piece distal of lower 1st molar to the most anterior tooth of each
of dead-soft SS wire or a brass wire can be contoured quadrant. 2nd molars are not part of the COS as they are
to the arch and measured. often not fully erupted and may be aligned by tipping them
2. Space required assessment distally, therefore, not requiring any space creation. The
distance from the deepest point of the COS to the lower oc-
The space required represents the sum of the mesiodistal
• Tooth enlargement or build-ups • Brass wire/ Caliper Method: To measure the space
available with this technique, adapt a brass wire to the
• Space opening for prostheses line of occlusion, conforming close to the archform and
• Mesial change in molar straighten it out in a line. To calculate space required,
measure the individual mesiodistal width of each tooth
Advantages and disadvantages of RLSA and add them together (Nance, 1947). The weaknesses
RLSA is a systematic method of analysis and treatment plan- of this technique is over-estimation of the available
ning, considering the main factors with require or generate space (Johal and Battagel, 1997).
space. Although the RLSA has been shown to be reliable and • Microscopic reflex technique: This technique uses a
valid its use has the following disadvantages: reflex microscope connected to a personal computer
• Does not account for vertical and transverse problems installed with a customized program. To calculate space
available, the software simply subtracts from the total
• Does not significantly affect decision for treatment tooth widths the mesiodistal overlaps of adjacent teeth,
planning including permanent first molars, making calculations
• Tends to overestimate crowding in millimeters. This technique have been previously
shown to be precise (Johal et al., 1995, Battagel, 1996),
• Tends to drive treatment plan towards extractions
however, the possible problems are expensive to use,
Is Royal London Space Analysis Reliable and does it influ- requires use of a specific computer program and the
ence orthodontic treatment decisions? maximum mesio-distal width is difficult to record if the
teeth are severely tipped.
Dr Al-Abdallah in her study found that (Al-Abdallah et al.,
2008): Methods of size estimation for unerupted teeth (Mixed
Dentition Space Analysis)
• RLSA is reliable.
Space analysis in mixed dentition requires estimation of
• RLSA did not influence treatment decision.
the size of unerupted teeth. This can be done in one of four
• RLSA may have an influence on visual perception. ways:
• RLSA does not have an impact on judgmental variation. 1. Study model and prediction table method
Moyer found a correlation between lower incisors and un-
erupted canine and premolars in a sample of North Ameri-
• 17.4% of the sample had anterior tooth width demonstrate final positions. The teeth are held in their
ratios and 5.4% had total arch ratios greater than 2 new positions with wax.
standard deviations from the average mean.
Expressing tooth size discrepancy in mm is prefer- • DS can be performed digitally.
able to standard deviation approach. Therefore, a • DS is beneficial in that it aids patient understing
requirement of tooth size correction of 2mm is an
appropriate threshold for clinical significance.
Exam Night Review
Average widths of permanent teeth (mm)
Clinical application of space analysis
Maxillary 8.5 6.5 7.5 7.0 7.0 10.5 9.5 8.5
• Diagnosis,
1 2 3 4 5 6 7 8
Man- 5.0 5.5 7.0 7.0 7.0 10.5 9.5 8.5 • Treatment planning,
dibular • Planning of anchorage,
Bolton ratios, malocclusion and gender • Planning the mechanics,
Different authors have compared Bolton ratios in differ- • Analysis of space requirements,
ent malocclusions; maxillary tooth size excess tendency
• Informed consent.
was present in Class II malocclusions and a tendency for
mandibular tooth excess in Class III (Nie and Lin, 1999). Arch perimeter: Mesial contact of the 6 to the mesial con-
Another study also found a significant mandibular excess in tact of the contralateral 6
Class III patients and an overall decreased Bolton ratio in
Arch width intermolar: Mesiobuccal cusp tip of the 6 to
Class II cases (Araujo and Souki, 2003). From these find-
the mesiobuccal cusp tip point of the contralateral 6
ings, it can be speculated whether these discrepancies have
a role in establishing the associated incisor relationship with Arch width intercanine: Canine cusp tip to canine cusp tip
a malocclusion or if the skeletal discrepancy in a jaw and
Arch Depth: The distance from a line perpendicular to the
its compensatory increase in tooth size results from growth
mesial surface of the permanent first molars to the midpoint
controlled mechanisms
of central incisors at its greatest depth.
Bolton ratios and ethnic groups
Arch expansion: Widening of the dental arch.
Many studies have investigated a relationship between
Arch lengthening: Increase of arch length by posterior
ethnic groups and Bolton ratios. A study demonstrated a
distalization or anterior proclination of incisors.
small but significant difference between Hispanic, black and
white groups (Smith et al., 2000). A significant difference Permanent Dentition Space Analysis
was found between gender groups, suggesting that the entire RLSA consists of two main domains: space requirement and
Bolton sample was made up of white females. On the other space provision.
hand, some study showed that different malocclusions or
either genders do not present any significant difference in Assessment of Space Requirement
• Incremental/ differential growth (positive for advanc- (Othman and Harradine, 2007) showed that:
ing Class II, and negative for advancing class III with a • Repeated measurements recommended
deterioration in arch relationship expected)
• Computerized methods of assessment are superior in
• Angulation changing sensitivity to visual methods
• Leeway space • 17.4% of the sample had anterior tooth width ratios and
Space can be utilised via: 5.4% had total arch ratios greater than 2 standard devia-
tions from the average mean
• Tooth enlargement or build-ups
• Expressing tooth size discrepancy in mm is preferable.
• Space opening for prostheses Requirement of tooth size correction of 2mm threshold
• Mesial change in molar for clinical significance
ADKINS, M. D., NANDA, R. S. & CURRIER, G. F. 1990. Arch NGAN, P., ALKIRE, R. G. & FIELDS JR, H. 1999. Management of
perimeter changes on rapid palatal expansion. Am J Orthod Den- space problems in the primary and mixed dentitions. The Journal
tofacial Orthop, 97, 194-9. of the American Dental Association, 130, 1330-1339.
AL-ABDALLAH, M., SANDLER, J. & O’BRIEN, K. 2008. Is the NIE, Q. & LIN, J. 1999. Comparison of intermaxillary tooth size
Royal London Space Analysis reliable and does it influence orth- discrepancies among different malocclusion groups. American
odontic treatment decisions? Eur J Orthod, 30, 503-7. Journal of Orthodontics and Dentofacial Orthopedics, 116, 539-
544.
ARAUJO, E. & SOUKI, M. 2003. Bolton anterior tooth size
discrepancies among different malocclusion groups. The Angle O’HIGGINS, E. A. & LEE, R. T. 2000. How much space is created
orthodontist, 73, 307-313. from expansion or premolar extraction? J Orthod, 27, 11-3.
BATTAGEL, J. M. 1996. Individualized catenary curves: their rela- OTHMAN, S. A. & HARRADINE, N. W. 2007. Tooth-size dis-
tionship to arch form and perimeter. Br J Orthod, 23, 21-8. crepancy and Bolton’s ratios: the reproducibility and speed of two
methods of measurement. J Orthod, 34, 234-42; discussion 233.
BOLTON, W. A. 1958. Disharmony in tooth size and its relation to
the analysis and treatment of malocclusion. The Angle Orthodon- PROFFIT, W. R. 2000. Masters of esthetic dentistry: The soft tissue
tist, 28, 113-130. paradigm in orthodontic diagnosis and treatment planning: A
new view for a new century. Journal of Esthetic and Restorative
CHAMPAGNE, M. 1992. Reliability of measurements from photo- Dentistry, 12, 46-49.
copies of study models. J Clin Orthod, 26, 648-50.
PROFFIT, W. R. F., FIELDS JR, H. W. & SARVER, D. M. 2012.
CROSBY, D. R. & ALEXANDER, C. G. 1989. The occurrence of Contemporary Orthodontics, 5e, Elsevier India.
tooth size discrepancies among different malocclusion groups. Am
J Orthod Dentofacial Orthop, 95, 457-61. SAATÇI, P. & YUKAY, F. 1997. The effect of premolar extractions
on tooth-size discrepancy. American journal of orthodontics and
GILL, D. S. & NAINI, F. B. 2012. Orthodontics: Principles and dentofacial orthopedics, 111, 428-434.
practice, John Wiley & Sons.
SCHIRMER, U. R. & WILTSHIRE, W. A. 1997. Manual and
HO, C. T. & FREER, T. J. 1999. A computerized tooth-width analy- computer-aided space analysis: a comparative study. Am J Orthod
sis. J Clin Orthod, 33, 498-503. Dentofacial Orthop, 112, 676-80.
JAROONTHAM, J. & GODFREY, K. 2000. Mixed dentition space SMITH, S. S., BUSCHANG, P. H. & WATANABE, E. 2000. Inter-
analysis in a Thai population. Eur J Orthod, 22, 127-34. arch tooth size relationships of 3 populations: “does Bolton’s analy-
JOHAL, A. S. & BATTAGEL, J. M. 1997. Dental crowding: a com- sis apply?”. Am J Orthod Dentofacial Orthop, 117, 169-74.
parison of three methods of assessment. Eur J Orthod, 19, 543-51. STALEY, R. N. & KERBER, P. E. 1980. A revision of the Hixon and
JOHAL, K., CRAIG, G., DEVLIN, A., BROOK, I. & HILL, R. 1995. Oldfather mixed-dentition prediction method. Am J Orthod, 78,
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increasing soda or calcium fluoride content. Journal of Materials
STEYN, C. L., HARRIS, A. M. & DU PREEZ, R. J. 1996. Anterior
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Royal London Space Planning: an integration of space analysis TOMASSETTI, J. J., TALOUMIS, L. J., DENNY, J. M. & FISCHER,
and treatment planning: Part I: Assessing the space required to J. R., JR. 2001. A comparison of 3 computerized Bolton tooth-size
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448-55.
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Royal London Space Planning: an integration of space analysis and
treatment planning: Part II: The effect of other treatment proce-
dures on space. Am J Orthod Dentofacial Orthop, 118, 456-61.
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Dentofacial Orthop, 115, 305-13.
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In this Chapter
• Severity: Defined as how far a malocclusion deviates • Occlusal classification such as Angle’s, incisor and
from normal. canine classifications.
Uses of orthodontic indices 1. Indices used for diagnostic purposes such as:
There are different types of orthodontic indices depending • Class 3 (mesiocclusion/ Pre-normal): when the
on their applications and purposes, these include: mesiobuccal cusp of the upper first permanent molar
occludes distal to the buccal groove of the lower first
52 Orthodontic Indices
permanent molar • Modification to the incisor classification includes
Class 2 indefinite which means that one upper cen-
Modification to Angle’s classification
tral incisor is retroclined, and the other is proclined
Includes Class 2 subdivision (Class 2 molar on one side
(Gravely and Johnson, 1974) and Class 2 intermediate
and class 1 molar on the other side) and Class 3 subdivision
which refers to a clinical situation where the upper inci-
(Class 3 molar on one side and class 1 molar on the other
sors are upright or slightly retroclined, and the overjet is
side). Angle’s classification is a simple, widely accepted,
5-7 mm (Williams and Stephens, 1992).
reliable and reproducible method of occlusal classification.
However, it cannot be used in primary dentition, the dental Skeletal classification
or skeletal original of aetiology cannot be distinguished, it
Skeletal classification is obtained through clinical assessment
can only assess discrepancies in the sagittal direction. More-
and supported with cephalometric analysis. Three skeletal
over, this method depends on the first permanent molars
categories are described using ANB angle:
being fixed points in the jaw structure, which is not valid, as
environmental factors can affect their position. • Class 1: Lower dental base is related to the upper
dental base (ANB= 2-4˚).
Full unit Class 2 and Class 3 malocclusion
• Class 2: Lower dental base is retruded relative to the
One unit is defined as the mesial-distal width of a premolar
upper dental base (ANB> 4˚).
and represents the distance from the mesiobuccal cusp tip
to the distobuccal cusp tip of the first permanent molar. Full • Class 3: Lower dental base is protruded relative to
unit Class 2 means that the mesiobuccal cusp of the upper the upper dental base (ANB <2˚).
molar is one unit mesial to the buccal groove of the lower
Wits appraisal and Ballard conversion can be used similarly
molar, i.e., the upper molar’s mesiobuccal cusp occludes in
to ANB.
the embrasure space of the lower second premolar and lower
first permanent molar. While, full unit class 3 means that Index of Orthodontic Treatment Need (IOTN)
the mesiobuccal cusp of the upper molar is one unit distal to IOTN was developed by Brook (Brook and Shaw, 1989),
the buccal groove of the lower molar, i.e., the upper molar’s who developed a specific ruler to aid assessment. IOTN
mesiobuccal cusp occludes in the embrasure space of the has two components: Dental health component (DHC) and
lower first permanent molar and second molar. Fractions of Aesthetic component (AC).
the unit are also used, commonly ¼, ½ , ¾ unit Class 2 and
Class 3
Incisor classification With regards to the Dental Health Component (DHC),
Brook and Shaw showed the reproducibility of the DHC is
The incisor classification was developed by the British very good (86.4%), and agreement was moderate for intra
Standards Institutes in 1983. It is based on the lower incisor and inter-examiner agreement (0.84-0.71). They also found
edges and the upper central incisor cingulum plateau. These that the common trait causing disagreement in descending
include: order of frequency are: crowding, increased overjet, cross-
• Class 1: The lower incisor edges occlude with or lie bites and overbites (Brook and Shaw, 1989).
immediately below the cingulum plateau of the upper With regards to the Aesthetic Component (AC), a high
incisors. level of agreement was found between patients, parents and
• Class 2: The lower incisor edges occlude or lie orthodontists when grading the patient’s AC (0.75-0.89)
posterior to the cingulum plateau of the upper incisors. (Evans and Shaw, 1987). This was supported by a separate
Two divisions of this class were described: study which showed the correlation coefficient was reason-
ably high (Brook and Shaw, 1989).
1. Division 1: The upper incisors are pro-
clined or normal inclination, with an increased
overjet. Dental health component (DHC)
2. Division 2: The upper central incisors are This was developed based on the index treatment priority
retroclined (lateral incisors may be retroclined used by the Swedish Dental Board. It attempts to rank mal-
or proclined). The overjet is usually decreased occlusion, and it is used as a clinical tool to assess eligibility
but may be increased. for NHS treatment. The DHC consists of 14 qualifiers and
• Class 3: The lower incisor edges occlude or lie 5 grades (Figures 1 and 2). Only the highest-scoring trait
anterior to the cingulum plateau of the upper incisors. needs to be recorded, as this determines the patient’s grad-
Overjet is usually reduced or reversed. ing. Grades 1 and 2 represent no need for orthodontic treat-
ment, grade 3 refers to the borderline need for treatment
Orthodontic Indices 53
while grades 4 and 5 indicate the definite need for treatment. 4b, 4m,5m) (Figure 3). If the reverse overjet is greater than 1
mm, it is essential to investigate whether the individual has
masticatory or speech (M&S) difficulties and classify
a overjet h hypodontia
b reverse overjet with no masticatory or speech i posterior lingual crossbite
problems
c crossbite m reverse overjet with masticatory or speech problems
d deisplacemnet of contact points p defects of cleft lip and palate
e open bite s submerged deciduous teeth
f deep bite t partially erupted teeth, tipped and impacted against adjacent
teeth
g good occlusion x presence of supernumerary teeth
Table 1: Abbreviations used in IOTN
accordingly. There are several methods of investigation, but
Scoring the DHC a simple approach is to ask the individual to count from 60-
Scoring the DHC is performed in order as follows MOCDO 70, noting any difficulty in pronunciation. In addition, any
which stands for: M - Missing teeth, O – Overjet, C – Cross- signs and symptoms of mandibular dysfunction should be
bites, D - Displacements and O – Overbite. checked.
1. Missing teeth (5i, 5h or 4h) relates to impacted/ impeded Positive Overjet Reveres Overjet
eruption and hypodontia.
2. a compe- 3.5mm - 2. b 0mm - 1mm
• Impeded eruption (5i) is a score for a tooth that is tent lips 6mm
not accommodated in the arch due to a lack of space 3. a incom- 3.5mm - 3. b 1mm -
or obstruction. The tooth is considered impeded if petent lips 6mm 3.5mm
the space remaining is less than or equal to 4mm,
4. a 6mm - 4. m M&S prob- 1mm -
and the angulation is not favourable in the horizon-
9mm lems 3.5mm
tal direction. In the mixed dentition, if the distance
from the mesial contact point of the first permanent 4. b No M&S greater than
molar to the distal contact point of the lateral incisor problem 3.5mm
is less than 18 mm or 17 mm in the upper and lower 5. a greater 5.m M&S prob- greater than
dental arches, respectively, the unerupted canine is than lem 3.5mm
considered impacted. 9mm
• Hypodontia (5.h or 4.h): The IOTN classification Table 2: Positive and negative overjet in IOTN
of hypodontia is only used if the space requires
orthodontic treatment, i.e., space opening or space 3. Crossbite: When 1, 2 or 3 (but not all) incisors are in lin-
closure. If there is no requirement for orthodontic gual occlusion/crossbite, the relationship is classified as ante-
treatment, i.e., accept space or primary tooth in situ, rior crossbite (2.c, 3.c, 4.c, 4.l) (Table 3). Posterior crossbite
this does not meet the IOTN classification due to no means that the posterior tooth or teeth are in full crossbite
orthodontic treatment being required. 5h means in a buccal or lingual perspective or cusp to cusp and might
extensive hypodontia with more than one tooth be associated with a displacement. The grade recorded
missing in a quadrant, requiring pre-restorative or- depends on the severity of discrepancy between retruded
thodontics. 4h means less extensive hypodontia, one contact position (RCP) and intercuspal position (ICP). The
tooth missing in a quadrant, requiring orthodontic greater the discrepancy between RCP an ICP, the higher the
space closure or pre-restorative orthodontics. grade. Scissor bite means that the entire buccal segment in
lingual occlusion.
2. Overjet is measured using the ruler held parallel to the
occlusal plane and radial to the line of the arch (2a, 3a, 4a, Grade and Qualifier Discrepemcy between IP and RCP
5a) (Table 2). The overjet is recorded to the labial aspect of 2.c 1<=1mm
the incisal edge of the most prominent incisor (lateral or
central incisors). The lower grade is allocated if the incisor 3.c 1 - 2mm
falls on the IOTN ruler line. Reverse overjet applies when 4.c >2mm
all four incisors are in lingual occlusion/crossbite (2b, 3b,
Table 3: Crossbite in IOTN
54 Orthodontic Indices
Grade 5 Increased overjet > 9mm
(very great) Extensive hypodontia with restorative implicatoins (more than one tooth missing in any quadrant) requir-
ing pre-restorative orthodontics
Impeded eruption of teeth (with the exception of the third molars) due to corwding, displacements, the
presence of supernumeray teeth, retained deciduoud teeth and any pathological cause
Reverse overjet greater than 3.5mm with reported masticatory and speech difficulities
Defects of cleft lip and palate
Submerged deciduous teeth
Grade 4 Increased overjet > 6mm but 9mm
(great) Reverse overjet > 3.5mm with no masticatory or speech deifficulties
Anterior or posterior crossbite with > 2mm discrepency between returded contact position and intercuspal
position
Servere displacemetns of teeth > 4mm
Extreme lateral or anterior openbite > 4mm
Increased and complete overbite with labial or palatal trauma
Less Extensive hypodontia (one tooth missing per quadrant) requiring prerestorative othodontics or orth-
odontic space closure to obviate the need for a prosthesis
posterior lingual cross bite with no functional
occlusal contact in one or more buccal segments
Reverse overjet greater than 1mm but 3,5 mm with recorded masticatory and speech difficulties
Partially erupted teeth, tipped and imapcted against adjacent teeth
Supplemental teeth
Grade 3 Increased overjet > 3.5 mm but 6mm with incompetent lips
(moderate) Reverse overjet greater than 1mm but 3.5mm
Anterior or posterior cross bite with > 1mm but 2mm discrepency between returded contact position and
intercuspal position
Displacement of teeth > 2mm but 4mm
Lateral or anterior open bite greater than 2mm but 4mm
Grade 2 Increased overjet > 3.5 mm but 6mm with competent lips
(Little) Reverse overjet greater than 0mm but 1mm
Anterior or posterior cross bite with 1mm discrepency between returded contact position and intercuspal
position
Displacement of teeth > 1mm but 2mm
Anterior posterior openbite > 1mm but 2mm
Increased overbite 3.5mm without gingival contact
Prenormal or postnormal occlusions with no other anomalies. includes up to half a unit discrepency
Grade 1 EXtremely minor malocclusions including displacements < 1mm
(None)
Table 4: Dental health component (DHC) of IOTN
Orthodontic Indices 55
4. Displacement of contact points (2.d, 3.d, 4.d) (Table or poor colour matching in anterior restorations.
5) Contact point displacement represents the degree of
Within the UK NHS a patient with a DHC of 3 or more, and
anatomical contact points deviation from the line of the
an AC of 6 or more, qualify for state-funded NHS treatment.
arch and only the worst displaced tooth is recorded, how-
Treatment priority and need according to the AC scale are:
ever, vertical displacements from the occlusal plane are not
recorded. Spacing is not also recorded unless the contact • Grades 1-3: No/slight need for treatment.
point is displaced from the line of the arch. Contact points
• Grade 4: Mild need for treatment.
displacement between deciduous and permanent, and that
due to teeth rotation (generally premolars) are not recorded. • Grades 5-7: Borderline need for treatment.
• Grades 8-10: Definite need for orthodontic treat-
Grade and Qualifier Displacement
ment.
2. d 1mm - 2mm
3. d 2.1mm - 4mm Overbite Openbite
4. d greater than 4mm Grade Grade
and and
Table 5: Contact point displacement in IOTN Qualifier Qualifier
5. Overbite and openbite (2.e/f, 3.e/f, 4.e/f) (Table 6): Deep 2. f Increased 2.e Anterior or pos-
bite and open bite apply to any of the four incisors. The larg- greater than or terior openbite
est vertical discrepancy is recorded. It is important to record equal to 3.5mm 1mm - 2mm
gingival or palatal trauma as a result of a deep overbite. 3.f Deep overbite 3.e Anterior or pos-
Other criteria of the DHC complete on terior openbite
labial or palatal 2.1mm - 4mm
These include:
tissues but no
• Buccal occlusion (2g): The buccal occlusion is as trauma
• sessed irrespective of whether the teeth interdigitate 4.f Increased 4.e External lateral
in Angle’s Class 1, 2 or 3. and complete openbites great-
overbitewith er than 4mm
• Tipped teeth (4t): When a permanent tooth has labial or palatal
erupted and is tipped against an adjacent tooth. trauma
• Submerging teeth (5.s): Submerged teeth are not re- Table 6 : Overbite and openbite in IOTN
corded unless only two cusps remain visible and/or
the adjacent teeth are tipped towards the submerged
tooth. Index of Orthognathic Functional Treatment Need
• Supernumerary teeth (4.x): It is graded only if a su (IOFTN)
pernumerary tooth requires extraction followed by IOFTN was developed in 2014. It prioritizes severe maloc-
orthodontic alignment and/or space closure. clusions due to skeletal abnormalities, not amenable to
Aesthetic Component (AC) orthodontic treatment alone. It applies to patients who have
completed facial growth (Ireland et al., 2014) (Figure 9).
AC was developed by Evans (Evans and Shaw, 1987) and it
was originally called the SCAN (Standardised Continuum he advantages of IOFTN including being reliable and
of Aesthetic Need) (Figure 7 and 8). The photographs were straightforward to use (Howard-Bowles et al., 2017) and
originally arranged in order by a panel of lay persons. The both digital and plaster models can be used (McCrory et al.,
AC is a ranking system 1-10 using coloured photographs 2018). However, the limitation of IOFTN are that this index
which assess dental attractiveness. The number 1 is the most only relates to the functional need for treatment, it does not
attractive while number 10 is the least attractive (figure 7). include psychological and other clinical indicators for treat-
The grading is made by the clinician by best matching the ment. Moreover, Class 3 malocclusion patients benefit more
patient front occlusion to AC photographs but not specific from this index than patients with class 2 skeletal patterns
morphological similarities to the photo. (Borzabadi-Farahani et al., 2016).
56 Orthodontic Indices
IOTN. Peer Assessment Rating (PAR)
Advantages Disadvantages This index was developed by Richmond and team (Rich-
mond et al., 1992). It was formulated over a series of six
Valid Crowding represented a prob- meetings in 1987 with a group of 10 experienced orthodon-
lem in recording when the pa- tists. The index can record the malocclusion at any stage of
tient is in the mixed dentition. treatment where a score is assigned to various occlusal traits
Reproducible The AC has no side view rating of a malocclusion. The individual scores are summed to ob-
or class III malocclusion tain an overall total, representing the degree a case deviates
Acceptable to clinician Objective index from ideal alignment and occlusion.
Easy and quick to apply No representation of aesthetic Study models are used for scoring along with a specifically
or skeletal relationship designed ruler that has all the information summarized
Can be used directly on No assessment of crowding which makes measurement quick and easy to perform.
patients or on dental which relies on displacement A total score of zero indicates good alignment and higher
casts only scores (rarely beyond 50) indicate significant levels of ir-
Yield quantitative data regularity. The difference between the pretreatment and
which can be analysed posttreatment scores represent the degree of improvement as
a result of orthodontic intervention and active treatment.
Table 7: Advantages and disadvantages of the IOTN
A
There are 11 components of the PAR index:
1. Upper anterior segment.
2. Lower anterior segment.
3. Upper right segment.
4. Upper left segment.
5. Lower right segment.
6. Lower left segment.
7. Right buccal occlusion.
8. Left buccal occlusion.
Figure 7: Monochromic copy of AC scale. 9. Overjet.
10. Overbite.
11. Centreline
Anterior segments
Anterior segments with a weighting of 1, extends from the
mesial anatomical contact point of the canine to the mesial
anatomical contact point of the canine on the contralateral
side (Table 8). Displaced contact points are not recorded for
the first, second and third molars, this is because contact
points are broad and are extremely variable within the
normal range. Displaced contact points are recorded at the
shortest distance between contact points, parallel to the
occlusal plane. The occlusal features recorded are crowding,
spacing, and impacted teeth.
In the case of potential crowding in the mixed dentition,
Figure 8: Aesthetic component of the IOTN average mesiodistal widths are used to calculate the space
deficiency. Impacted teeth are recorded when the space
available for the tooth is equal or less than 4 mm (Table 9).
Orthodontic Indices 57
5. Very great need of treatment
Defects of cleft lip and palate and other craniofacial anomalies
Increased overjet greater than 9mm
Reverse overjet >= 3mm
Open bite >= 4mm
Complete scissors bite affecting whole buccal segments with sign of functional disturbance and or occlusal trauma
Sleep apnoea not amenable to other treatments such as MAD or CPAP (as determined by sleep studies)
Skeletal anomalies with occlusal disturance as a result of trauma or pathology
4. Great need of treatment
Increased overjet >= 6mm and <=9mm
Reverse overjet >= 0mm and < 3mm with functianl difficulties
Openbite < 4mm with functioanl difficulties
Increased overbite with evidence of dental or soft tissue trauma
Upper labial segment gingival exposure 3>= at rest
Facial asymmertry assocaited with occlusal disturbance
3. Moderate need of treatment
Reverse overjet >= 0mm and <3mm with no functionl difficulties
Open bite < 4mm with no functional difficulties
Upper labial segment gingival exposure <3mm at rest, but with evidence of gingival/periodontal effects
Facial asymmetry with no occlusal disturbance
2. Mild need of treatment
Increased overbite but no evidence of dental or soft tisssue trauma
Upper labial segement gingival exposure < 3mm at rest with no evidence of gingival/periodontal effects
Facial asymmetry with no occlusal disturbance
1. No need of treatment
Speech Difficulties
Treatment purely for TMD
Occlusal features not classified above
Table 9: An Index of Orthognathic Functional TreatmentNeed (IOFTN)
58 Orthodontic Indices
Table 10: Mixed dentition crowding assessment using Overjets and crossbites are recorded collectively, therefore, if
average mesio-distal width there is a positive overjet and one of the incisors or canines
in crossbite, the scores should be added together. Overjet
Upper has a weighting of 6.
Canine 8mm Total 22mm
Table 12: Overjet component measurements
1st Premolar 7mm Impaction < =
18mm Overjet Anterior crossbites
0 0-3 mm 0 No discrepancy
2nd Premolar 7mm
1 3.1- 5mm 1 One or more teeth
Lower edge to edge
Canine 7mm Total 21mm 2 5.1- 7mm 2 One single tooth in
1st Premolar 7mm Impaction < = crossbite
2nd Premolar 7mm 17mm 3 7.1- 9mm 3 Two teeth in cross-
bite
Buccal occlusion
4 Greater than 4 More than two
Buccal segments, with a weighting of 1, extends from the 9mm teeth in crossbite
mesial anatomical contact point of the last molar (whether
this was the first, second or third molar) to the distal ana-
tomical contact point of the canine in the same quadrant. Overbite
Recordings of both right and left sides in occlusion in three The vertical overlap (OB) or openbite (AOB) of the anterior
dimensions (A-P, vertical and transverse) is performed teeth is recorded (Table 13 & 14). The tooth with the greatest
(Table 10). Temporary developmental stages and submerg- overlap is recorded, if the OB and AOB are present, then they
ing deciduous teeth are excluded should be added. Overbite has a weighting of 2.
Table 11: Buccal occlusion assessment Table 13: Overbite component measurements
PAR Score Table 4: Buccal occlusion Open bite
discrepancy
0 No openbite
Vertical
1 Openbite less than and equal to
0 No discrepancy in intercuspa- 1mm
tion
2 Openbite 1.1 mm – 2 mm
1 Lateral open bite on at least 2
teeth greater than 2 mm 3 Openbite 2.1 mm- 3 mm
Antero-posterior 4 Openbite greater than or equal
4mm
0 Good interdigitation (Cl 1, Cl
2 or Cl 3) Table 14: Deep bite component measurements
1 Less than ½ unit discrepancy
0 Less than or equal to 1/3
2 ½ a unit discrepancy (cusp to
coverage of the lower incisor
cusp) or more
1 Greater than 1/3, but less
Transverse
than 2/3 coverage of the
0 No crossbites lower incisor
1 Crossbite tendency
2 Greater than 2/3 coverage of
2 Single tooth in crossbite the lower incisor
3 More than 1 tooth in crossbite 3 Greater than or equal to full
4 More than 1 tooth in scissor tooth coverage.
bite
Centerlines
Overjet
Centerline discrepancy is assessed in relation to the lower
The most prominent aspect of any incisor (central or lateral) central incisors (Table 15). If a lower incisor is missing, mea-
is recorded with a ruler held parallel to the occlusal plane surement is not recorded. Centerlines has a weighting of 4.
(Table 12).
Orthodontic Indices 59
Table 15: Centrelines component measurements provement or worse outcome.
PAR Score Table 8: Centrelines discrepancy as- • Graphical assessment: Assessment using a graph
sessment (nomogram).
0 Coincident and up to ¼ lower inci- Index Of Complexity Outcome & Need (ICON)
sor width
1 ¼ to ½ lower incisor width ICON index was purposed by Daniels (Daniels and Rich-
2 Greater than ½ lower incisor width mond, 2000) as the first index based on international orth-
odontic opinion of 97 orthodontists. ICON index comprises
Advantages of PAR index of an assessment of five traits, each trait is multiplied by a
These include: weighting factor. The final score is the sum of all the five trait
scores. ICON scoring and interpretations are provided in
• It has been reported that the PAR index has ex- Table 16 & 10.
cellent reliability within intra and inter-examiner
agreement (0.93-0.87) (Richmond et al., 1992). he traits which make up the ABO DI are presented in Table
10 and include:
• Easy and quick with use of the PAR ruler.
• Overjet and anterior crossbite.
• PAR can be used for all types of malocclusion and
treatment modalities. • Overbite and anterior open bite and lateral open-
bite.
• The score provides an estimate of how far a case de-
viates from normal. • Crowding.
• It provides a single summary score for all the oc- • An additional category designated ‘other’ is pre-
clusal anomalies, and is therefore not related to an served for conditions that may affect or add to the
individual patient’s needs. complexity of treatment.
• The reliability of the upper buccal segments was Need and acceptability Threshold values
found to be low, this was due to the variation of up- Pretreatment need >43 Treatment need
per posterior tooth size. Larger teeth have broader
contact points which result in inaccurate assessment
End treatment acceptability < 31 Acceptable
(Richmond et al., 1992).
Complexity grade (Pretreatment) Score range
• Hamdan and Rock suggested the PAR index over- Easy < 29
weights the overjet (weighting of 6), and under Mild 29 to 50
weights the overbite (weighting of 2) (Hamdan and
Moderate 5 1 to 63
Rock, 1999).
Difficult 64 to 77
Outcome assessment of PAR Very difficult > 77
There are three methods of assessing outcome using the PAR Improvement Grade Score Range
Index. (Pretreatment score – 4x Post-
treatment score)
• PAR score change: Reduction from pre-treatment to
post-treatment PAR score. 22-point reduction indi- Greatly improved > -1
cates great improvement. Substantially improved -25 to - l
Moderately improved -53 to -26
• PAR percentage change: Percentage change from
pre-treatment to post-treatment. A percentage im- Minimal improved -85 to -54
provement greater than 70% can be considered a Not improved or worse < -85
good standard for orthodontic treatment. 30-70%
Table 16: Interpretation of ICON scores
reduction represents an improved outcome. Less
than 30% reduction is considered to be of no im-
60 Orthodontic Indices
Traits Weighting Score 0 1 2 3 4 5
factor
Aesthetic 7 1-10 as
judged us-
ing IOTN
AC
Upper Crowding 5 Only the Less than 2.1- 5mm 5.1- 9mm 9.1-13mm 13.1- More than
arch highest 2mm 17mm 17mm or
trait either impacted
spacing or teeth
crowding
Spacing 5 Up to 2.1-5mm 5.1- 9mm More than
2mm 9mm
Crossbite 5 Transverse No cross- Cross bite
relation- bites present
ship of
cusp to
cusp or
worse
Anterior Open bite 4 Only the Complete Less than 1.1-2mm 2.1-4mm More than
highest bite 1mm 4mm
trait either
openbite
or overbite
Deep bite 4 Lower Up to 1/3 1/3- 2/3 2/3 up to Fully
incisor tooth coverage full cov- covered
coverage ered
Buccal 3 Left and Cusp to Any cusp Cusp to
segment right embrasure relation up cusp rela-
anterio- added relation- to but not tionship
posterior together ship only, including
relation- C1, C2, cusp to
ship C3 cusp
Table 17: Scoring of ICON scores
American Board of Orthodontics Discrepancy Index If there is a negative overjet (anterior crossbite), the score is
(ABO DI) recorded as 1 point per mm. per anterior tooth in crossbite.
Overjet Overbite
Overjet is scored as the distance between the incisal edge of Positive overbite is scored as follow:
the most forward positioned upper incisor and the most for-
• Overbite of up to 3 mm: 0 point are scored.
ward positioned mandibular incisor:
• Overbite between 3.1 to 5 mm: 2 points are scored.
• Overjet of 0 mm (edge to edge): 1 point.
• Overbite between 5.1 to 7 mm: 3 points are scored.
• Overjet of 0 to 3 mm: 0 point.
If the lower incisors are impinging on the palatal tissue (100%
• Overjet of 3.1 - 5 mm: 2 points.
overbite), then 5 points are scored.
• Overjet of 5.1 - 7 mm: 3 points.
Anterior openbite is scored as follow:
• Overjet of 7.1 - 9 mm: 4 points.
• If the upper and lower incisors are in an edge to edge
• Overjet over 9 mm: 5 points. relationship (overbite = 0): 1 point is scored.
Orthodontic Indices 61
Table 18: ABO DISCREPANCY INDEX
Discrepency Index
Overjet 0mm
(edge to edge) 1pt
1mm - 3mm 0 pts Occlusion
3.1 - 5mm 2 pts Class I end on 0 pt
5.1 - 7mm 3 pts End on Class II or III 2 pts perside
7.1 - 9mm 4 pts Full Class II or III 4 pts per side
>9mm 5 pts Beyond Class II or III 1 pt per mm additional
Negative OJ(x-bite) 1 pt. per mm per tooth= Total _____________
Total _______________ Lingual Posterior X Bite
Overbite 1 pt per tooth Total
0 - 3mm 0 pt Buccal Posterior X Bite
3.1 - 5 mm 2 pts 2 pts per tooth Total _______
5.1- 7mm 3 pts Cephalometrics
Impinging 100% 5 pts ANB > 5.5 or < -1.5 4pts
Total _______________ Each additional degree 1 pt
Anterior Openbite SN -GO -GN 27 degree - 37 degree 0 pt
0mm (edge to edge)= 1pt SN -GO -GN > 37 degree 2 pts per degree
then 2 pts per mm per tooth SN -GO -GN < 27 degree 1 pt per degree
Total _____________ IMPA >98 degree 1 pt. per degree
Crowding Total____________
0 - 3mm 1 pt OTHER 2 pts
3.1 - 5mm 2 pts
5.1 - 7mm 7 pts INDICATE PROBLEMS
>7mm 7 pts _________________
Total ______________ _____________
• For each millimeter of openbite, 2 points are scored
for each upper tooth involved from canine to canine. Buccal Occlusion
• No points are scored for the upper canines if they When scoring occlusion, the Angle molar classification is
are buccally displaced out of the arch. used as below:
In terms of the lateral openbite, for each upper tooth (from • If the mesiobuccal cusp of the upper first molar oc-
the first premolar to third molar) in an openbite relationship cludes with the buccal groove of the mandibular first
with the lower arch, 2 points are scored per mm of openbite molar no points are scored (this includes 1/4 unit
for each tooth. class 2 or 3).
Crowding • If the occlusal relationship is 1/2 unit class 2 or 3
(cusp to cusp), then 2 points are scored per side.
When scoring crowding the most crowded dental arch is con-
sidered. The scoring include: • If the relationship is a full class 2 or 3, then 4 points
are scored per side.
• 1 to 3 mm:1 point is scored.
• If the relationship is greater or beyond a full unit
• 3.1 - 5 mm 2 points are scored.
class 2 or 3, then 1 additional point is scored per mm
• 5.1 - 7 mm 4 points are scored. for each side.
• Greater than 7 mm: 7 points are scored.
62 Orthodontic Indices
Posterior crossbite ards to oral health from the deformity, as well as the psycho-
social effects of dentofacial aesthetics, mandibular function
In lingual posterior crossbite, for each upper posterior tooth
and speech (Salzmann, 1968). The HMAR consists of:
in lingual crossbite (from the first premolar to the third mo-
lar), 1 point is scored. In buccal posterior crossbite, for each 1. Intra-arch deviations including:
upper posterior tooth (from the first premolar to the third
• Missing teeth.
molar) in complete buccal crossbite, 2 points are scored.
• Crowding.
Cephalometric analysis
• Rotations.
If ANB angle is greater than 5.5˚ or less than -1.5˚, 4 points
are scored. For each additional degree above or below these • Spacing.
values, an additional point is scored. If the SN-Go-Gn angle
2. Inter-arch relationships including:
is between 27 ˚ to 37˚, Zero points are scored, greater than
37˚, 2 points are scored. For each additional degree above • Overjet.
37˚, 1 point is scored and for each additional degree below • Crossbite.
27˚, 1 point is scored. If the Go-Gn angle is greater than 98˚,
1 point is scored for each additional degree above 98 ˚. • Overbite.
Other variables • Openbite.
At the discretion of the examiner, an additional 2 points may • Molar and canine relationships.
be awarded for each of the following conditions: Little irregularity (LI) index
• Missing teeth (except for third molars). LI was developed by Little (Little, 1975). It assesses the ir-
• Supernumerary teeth. regularity of the lower labial segment by measuring the linear
displacement of the contact points in mm (from the mesial
• Impactions (except for third molars). contact point of the canine to the mesial contact point of the
• Ectopic eruption. canine on the contralateral side). The sum of the 5 displaced
contact points represents the relative degree of anterior ir-
• Anomalies of tooth size and shape.
regularity (Table 11). It is used in the assessment of stability
• Dental midline discrepancies greater than 3 mm. and relapse. >3.5mm of irregularity is deemed unacceptable.
• Skeletal asymmetries (involving dental compensa- The advantages of LI index are being easy to use and it pro-
tion for case completion). vides the extent of post treatment relapse of incisor crowding.
However, the disadvantages of LI index are that the index is
Advantages of ABO DI
outdated method. If two teeth are crowded and rotated, but
• Detailed/comprehensive. maintain contact point proximity, LI does not register the
crowding.
• Measures case complexity. Case complexity however
is a subjective outcome. The information can be used Crowding index
to aide decisions of who should treatment the pa-
In occlusal view, crowding is determined by measuring the
tient. The ABO DI is used for case assessment for
available horizontal space, parallel to the occlusal plane, be-
board registration in America.
tween the least displaced interproximal contact points. The
Disadvantages of ABO DI actual width of the corresponding tooth was then deducted
from the available space to give a resultant amount of crowd-
These include:
ing (positive measure) or spacing (negative measure) for each
• Complicated to perform and time consuming. tooth.
• Time-consuming. Table 19: Irregularity Index
• Relies on cephalograms and therefore irradiation for Irregularity Score
indexing.
Perfect alignment 0mm
• Reproducibility is lower than other indices.
Minimal irregularity 1-3mm
Handicapping malocclusion assessment record Moderate irregularity 4-6mm
The purpose of the HMAR is to establish a priority index for Severe irregularity 7-9mm
treatment of dentofacial deformity. The HMAR factors haz- Very severe irregularity 10mm
Orthodontic Indices 63
Maxillary expansion indices • 2= Plaque at the gingival margin (visible to the eye).
It has been stated that there is a constant relationship between • 3= Heavy plaque accumulation on tooth.
the sum of the maxillary incisor widths (SI=Sum of Incisors
It is recommended to score the buccal and lingual surfaces of
width) and the width of the maxillary arch width in an ideal
the sextants of the arch (2 surfaces per index tooth). If an in-
uncrowded dentition. This method overestimated average
dex tooth is missing, score the nearest tooth in that sextant. If
maxillary widths.
no teeth are present, record the sextant as X. If plaque thick-
The formula was then transposed to allow arch width pre- ness varies along the gingival margin, score according to the
diction: Required inter-premolar width = SI/ 0.80 Required worst situation. The overall score is the sum of the buccal and
inter-molar width = SI/0.6. lingual surfaces of the 6 teeth (12 surfaces).
McNamara proposed a simple rule of thumb indicating an Calculation of plaque index
ideal average intermolar width in males is 37 mm and in fe-
The main features are:
males is 36 mm. However, this proposal overestimates the
average width. Schwarz built his analysis based on the face • Plaque index for a surface of a tooth range from 0-3.
type and SI. It is considered as an accurate method for maxil-
• Plaque index for an individual tooth: Buccal and lin-
lary arch width analysis. As per Schwarz, in a narrow face, the
gual scores are added and divided by two.
inter- first premolar width is equal to SI + 6 mm while the
intermolar width is equal to SI + 12 mm. the inter- first pre- • Plaque index for a group of teeth: Scores for individ-
molar width is equal to SI + 7 mm while the intermolar width ual teeth are added and then divided by the number
is equal to SI + 14 mm. While in broad faces, the inter- first of teeth examined.
premolar width is equal to SI + 8 mm while the intermolar • Plaque index for the individual: Score for each of the
width is equal to SI + 16 mm. teeth are added and then divided by the total num-
Treatment difficulty index for unerupted maxillary ca- ber of teeth examined.
nines • Plaque index for a group of people: All indices are
The prognosis for alignment of an impacted maxillary canine taken and divided by the number of individuals.
is affected by several factors which have been listed in order • Interpretation of plaque scoring is given in Table 12.
of greatest difficulty (McSherry, 1996) (Pitt et al., 2006):
Table 20: Interpretation of Plaque index
• Horizontal position.
• Age of patient. Rating scores
0 Excellent
• Vertical height.
0.1-0.9 Good
• Bucco-palatal position.
1.0-1.9 Fair
• Angulation to midline. 2.0-3.0 Poor
• Rotation. Gingival index (GI)
• Coincidence of arch midlines. GI assesses of prevalence and severity of gingivitis. It is rec-
• Alignment and spacing of the upper labial segment. ommended to score the four surfaces of tooth no. 16, 12, 24,
36, 32 and 44.GI scores are:
• Condition of primary canine.
• 0= Healthy.
• Missing teeth.
• 1= Mild inflammation, slight change in color.
Plaque index
• 2= Moderate inflammation, redness, moderate glaz-
The plaque index was developed by Silness and Loe (Silness
ing, bleeding on pressure.
and Loe, 1964). This index is used to easily and reliably record
• 3= Severe inflammation, redness, hyperplasia, ten-
the levels of supragingival plaque. However, plaque index
dency for spontaneous bleeding.
does not indicate plaque control nor record subgingival area.
It is subjective scoring in which the plaque is scored as: Basic Periodontal Examination (BPE)
• 0= No plaque at gingival margin. BPE was developed from the Community Periodontal Index
of Treatment Needs (CPITN) (Cutress et al., 1987). BPE
• 1= Initial deposit of plaque at gingival margin (not
should be undertaken on all patients undergoing orthodon-
visible to the eye).
64 Orthodontic Indices
tic treatment. The BPE divides the dentition into 6 sextants: clination of the incisors can be corrected more easily than
anterior crossbite with normal incisor inclination) and is
• Upper right 17 to 14.
therefore more useful than a specific anomaly-score alone.
• Upper anterior 13 to 23. Advantages and disadvantages of GOSLON index are listed
in Table 19.
• Upper left 24 to 27.
Table 21: Advantages and disadvantages of GOSLON
• Lower right 47 to 44.
yardstick
• Lower anterior 43 to 33.
Advantages Disadvantages
• Lower left 34 to 37.
1.It can differentiate be- 1.The judges should be
The highest score is recorded in each sextant using WHO tween arch relationships trained in the use of this
621 probe. The probe has a ‘ball end’ 0.5 mm in diameter, and interference of facial index and recalibration is
and a black band from 3.5 to 5.5 mm. Light probing force morphology necessary to assure consis-
should be used (20-25 grams). Examination is recorded as tency
follow:
2. Good inter and intra- 2. It only scores ULCP
• Code 0 - No pockets over 3mm, no calculus and examiner reliability
overhangs and no bleeding on gentle probing. 3. It shows clinical aspects 3. Its validity has not been
• Code 1 - No pockets over 3mm, no calculus/over- in 3 planes of study. investigated
hangs but bleeding on gentle probing. 4. Differentiates between 4. It is difficult since it
• Code 2 - No pockets over 3mm but calculus / the degree of malocclusion requires a cluster of adults
plaque retentive factors and bleeding on gentle during all stages of dental with UCLP who have been
probing would be present. development treated by primary surgery
only
• Code 3 – Pocket up to 3.5-5.5mm present (black
5. It can predict surgical 5. It is less powerful than an
band of probe partially visible, indicating pocket of
outcomes at an early age of objective constant numeri-
4-5 mm).
5 years cal measurement scale
• Code 4 – Pocket >5.5 mm (black band entirely
Tooth Wear Index
within the pocket, indicating pocket of 6 mm or
more) Smith and Knight introduced the tooth wear index which
assesses tooth wear on all four visible surfaces (Smith and
• * indicates furcation involvement.
Knight, 1984). It assesses pathological tooth wear (Table
Helkimo Clinical Dysfunction (HCD) Index 16). All teeth present are scored irrespective of the aetiology
of tooth wear. The tooth wear index measures multifacto-
This epidemiological index was introduced by Van Der
rial tooth wear and distinguishes between acceptable and
Weele (van der Weele and Dibbets, 1987). It measures sever-
pathological levels of wear. However, it takes a lot of time to
ity of TMJ dysfunction, however, it gives same weight to
measure the full dentition and it is also a research tool and
all symptoms regardless whether it is muscular to articular
cannot be used without computer assistance.
disorders. Other drawback associated with this index is
that the scale of 0, 1, 5 is not continuous, the index does not Root resorption indices
indicate the severity between score numbers, hence is it not
Root resorption classification score was originally proposed
a valid nor reproducible tool. The criteria for this index are
by Malmgren (Malmgren et al., 1982) and consists of four
provided in Table 22.
grades:
GOSLON index
• Grade 1: Irregularity in the apical root contour,
The GOSLON (Great Ormond Street, London and Oslo) maintaining the original root length.
index was introduced by Mars et al.(Mars et al., 1987) as a
• Grade 2: Resorption of up to 2mm of the root length.
clinical tool to allow categorization of the dental relation-
ships (Antero-posterior, vertical and transverse relationship) • Grade 3: Resorption from 2mm up to 1/3 of the root
in 10 years old patients with unilateral cleft lip/ palate. It is length.
valuable in predicting treatment need (orthodontic treat- • Grade 4: Severe root resorption above 1/3 of the root
ment, surgical treatment). length.
GOSLON index has five discrete categories. The GOSLON •
index is treatment-linked (e.g. anterior crossbite with retro-
Orthodontic Indices 65
Table 22: Criteria for Helkimo Clinical Dysfunction Index
Symptom Criteria Score
Impaired range of movement Normal range of movement 0
Slightly impaired mobility 1
Severe impaired mobility 5
Smooth Movement without joint sounds and deviation < 2mm 0
Impaired TMJ Function Joint sounds in one or both joints and deviation > 2mm on opening or closing 1
Locking or luxation of joint 5
Muscle Pain No tenderness to palpation 0
Tenderness to palpation in 1-3 sites 1
Tenderness to palpation in 4 or more sites 5
TMJ pain No tenderness to palpation 0
Tenderness to palpation in 1-3 sites 1
Tenderness to palpation in 4 or more sites 5
Pain on movement of mandible Pain on 1 movement 0
Pain on 2 or more movements 1
No pain on movements 5
This index was modified and expanded by Alamadi and • Grade 4: Root resorption exceeding 1/3 of the root’s
team into (Alamadi et al., 2017) original length.
• Grade 2: less than 1/4 of the root is resorbed. Score Surface Criteria
• Grade 3: 1/4 of the root is resorbed. 0 B/L/O/I/C No loss of enamel surface
characteristics.
• Grade 4: 1/2 of the root is resorbed.
No loss of contour.
• Grade 5: 3/4 of the root is resorbed.
1 B/L/O/I/C Loss of enamel surface
• Grade 6: Middle resorption (apex of the tooth is characteristics.
maintained). Minimal loss of contour.
Another index for root resorption is the Sharpe’s index 2 B/L/O/I/C Loss of enamel leading
(Sharpe et al., 1987) which also classified root resorption to dentine exposure for
into 4 categories less than one third of the
• Grade 1: No apical root resorption. surface.
Defect less than 1 mm deep.
• Grade 2: Slight blunting of the root apex.
3 B/L/O/I/C Loss of enamel leading
• Grade 3: Moderate blunting of the root apex up to ¼ to dentine exposure for
of the root length. less than one third of the
• Grade 4: Excessive blunting of the root apex beyond surface. Loss of enamel and
the ¼ of the root length. substantial loss of dentine
Defect between 1-2 mm
Levander and colleagues (Levander et al., 1998) develop
deep.
another 4 categoriesbased index for root resorption
4 B/L/O/I/C Complete enamel loss with
• Grade 1: Irregular root contour. pulp exposure or secondary
• Grade 2: Root resorption apically, less than 2mm dentine exposure.
(Minor). Defect more than 2mm
• Grade 3: Root resorption apically, from 2mm to 1/3 deep.
of the root’s length (severe). B: Buccal; L: Lingual; O: Occlusal; I: Incisal; C: Cervical.
66 Orthodontic Indices
Maxillary suture fusion index EXAM NIGHT REVIEW
Several methods for assessment of maturation of mid-palatal ORTHODONTIC INDICES
suture are available including chronological age, dental de- An orthodontic index or malocclusion index can be defined
velopmental age, CVM staging, five stage mid-palatal suture as a means of objectively assessing occlusal status.
maturation method and hand/ wrist radiograph.
Uses of orthodontic indices
Mid-palatal suture density ratio (MSDR) by Gruntheid
(Grünheid et al., 2017) • Epidemiology
MSDR by Gruntheid is a CBCT based technique that uses • Clinical assessment
GRAY levels substitute for measuring bone density levels of • Communication
the palatal regions. Ratio value 0 refers to less calcification
of sutures while ratio value 1 refers to more calcified sutures. General characteristics of an index
In comparison to other methods MSDR shows a greater cor • Reliable.
relation with the actual measurement of skeletal expansion.
•
Reproducible: Same classification with repeated
Five stage midpalatal suture maturation method (accord- evaluations.
ing to CBCT)
• Valid: The index should measure what it was intend-
It was proposed by Angelieri (Angelieri et al., 2013). Stage 1 ed to measure.
to 3 can benefit from conventional RME, but stages 4 and 5
require surgically assisted RME (Table 21). • Universally acceptable to profession and public.
Stage 1 Straight high-density sutural line at • Requires minimal adjustment.
midline, little or no interdigitation • Simple to administer.
Stage 2 Scalloped appearance of high-den-
• Cheap.
sity sutural line at midline
Stage 3 Parallel, scalloped high density Types of indices
lines close to each other (separated • Classification indices.
in some areas by small low-density
spaces) • Diagnostic indices
Stage 4 Fusion completed in palatine bone, • Treatment assessment (need, complexity and out-
no evidence of a suture come)
Stage 5 Fusion completed anteriorly (max- • Cleft outcomes
illary region)
• Oral health indices
Index of Orthodontic Treatment Need (IOTN)
Table 24: Five stage midpalatal suture maturation method
(according to CBCT) • IOTN was developed by Brook (Brook and Shaw,
1989).
• A specific ruler had been developed aid assessment.
• IOTN has two components:
1. Dental health component (DHC).
2. Aesthetic component (AC).
Dental health component (DHC)
• This was developed based on the index treatment
priority used by the Swedish Dental Board.
• It attempts to rank malocclusion and is used as a
clinical tool to assess eligibility for NHS treatment.
• The DHC consists of 14 qualifiers and 5 grades.
• Grade 1 represents little or no need for treatment,
and grade 5 represents the great need for treatment.
Orthodontic Indices 67
Ruler is used for measurement. (Ireland et al., 2014).
• Various abbreviations used in IOTN are given in fig- Peer Assessment Rating (PAR)
ure 1.
•
This index was developed by Richmond et
• The scoring of dental health components is given in al.(Richmond et al., 1992)
figure 2.
• A total score of zero indicates good alignment, and
• Only the highest-scoring trait needs to be recorded, higher scores (rarely beyond 50) indicate significant
as this determines the grading for the patient. levels of irregularity.
• Treatment priority and need according to DHC • The difference between the pretreatment and post-
• Grades 1 and 2 represent no need for orthodontic treatment scores represent the degree of improve-
treatment ment.
• Grade 3 refers to the borderline need for treatment • There are 11 components of the PAR index:
• Grades 4 and 5 indicate definite need for treatment 1) 1. Upper anterior segment.
2) 2. O - Overjet (5.a, 4.a, 3.a, 2.a / 5.m, 4.m, 4.b, 4) 4. Upper left segment.
3.b, 2.b) 5) 5. Lower right segment.
3) 3. C - Crossbites (4.c, 3.c, 2.c) 6) 6. Lower left segment.
4) 4. D - Displacements (4.d, 3.d, 2.d) 7) 7. Right buccal occlusion.
5) 5. O - Overbite (4.f, 3.f, 2.f / 4e, 3.e, 2.e) 8) 8. Left buccal occlusion.
Aesthetic Component (AC) 9) 9. Overjet.
• The AC is a ranking system 1-10 using coloured 10) 10. Overbite.
photographs which assess dental attractiveness. The
11) 11. Centrelines.
number 1 is the most attractive, while number 10 is
the least attractive. Outcome assessment of PAR
• The grading is made by the orthodontist matching • PAR score change: Reduction from pre-treatment
the patient to AC photographs but not specific mor- to post-treatment PAR score. 22-point reduction indicates
phological similarities to the photo. great improvement.
• In the UK, a patient with a DHC of 3 or more, and • PAR percentage change: Percentage change from
an AC of 6 or more, qualify for state-funded NHS pre-treatment to post-treatment. A percentage im-
treatment. provement more significant than 70% can be con-
sidered a good standard for orthodontic treatment.
• Treatment priority and need according to the AC
30-70% reduction represents an improved outcome.
scale:
Less than 30% reduction is regarded as no improve-
• Grades 123: No/little need for treatment. ment or worse outcome.
• Grade 4: Mild need for treatment. • Graphical assessment: Assessment using a graph
• Grades 5-7: Borderline need for treatment. (nomogram).
• Grades 8-10: Definite need for orthodontic treat- Index Of Complexity Outcome & Need (ICON)
ment. • ICON was the first index based on international
An Index of Orthognathic Functional Treatment Need orthodontic opinion and was proposed by Daniels
(IOFTN) (Daniels and Richmond, 2000).
• IOFTN was developed in 2014 and prioritised se- • The index was based on the opinion of 97 interna-
vere malocclusions due to skeletal abnormalities, tional orthodontists.
not amenable to orthodontic treatment alone. It ap- • This index is comprised of an assessment of five
plies to patients who have completed facial growth traits.
68 Orthodontic Indices
• Each trait is multiplied by a weighting factor. (Minor).
• The final score is the sum of all the five trait scores. • Grade 3: Root resorption apically, from 2mm to 1/3
of the root’s length (severe).
American Board of Orthodontics Discrepancy Index
(ABO DI) • Grade 4: Root resorption exceeding 1/3 of the root’s
original length.
The traits which make up the ABO DI are:
• Overjet and anterior crossbite.
• Overbite and anterior open bite and lateral openbite.
• Crowding.
• Buccal occlusion.
• Lingual posterior crossbite and buccal posterior
crossbite.
• Cephalometric analysis: Consisting of ANB angle,
SN-Go-Gn and lower incisor to Go-Gn angle.
• An additional category designated ‘other’ is pre-
served for conditions that may affect or add to the
complexity of treatment.
Basic Periodontal Examination (BPE)
Code 0 - No pockets over 3mm, no calculus and overhangs
and no bleeding on gentle probing.
Code 1 - No pockets over 3mm, no calculus/overhangs but
bleeding on gentle probing.
Code 2 - No pockets over 3mm but calculus / plaque reten-
tive factors and bleeding on gentle probing would be pres-
ent.
Code 3 – Pocket up to 3.5-5.5mm present (black probe band
partially visible, indicating pocket of 4-5 mm).
Code 4 – Pocket >5.5 mm (black band entirely within the
pocket, indicating pocket of 6 mm or more)
* - Furcation involvement.
Root resorption indices
Malmgren’s root resorption index (Malmgren et al., 1982)
• Grade 1: Irregularity in the apical root contour,
maintaining the original root length.
• Grade 2: Resorption of up to 2mm of the root length.
• Grade 3: Resorption from 2mm to 1/3 of the root
length.
• Grade 4: Severe root resorption above 1/3 of the root
length.
Root resorption index according to Levander (Levander et
al., 1998)
• Grade 1: Irregular root contour.
• Grade 2: Root resorption apically, less than 2mm
Orthodontic Indices 69
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RICHMOND, S., SHAW, W. C., O’BRIEN, K. D., BUCHANAN, I.
BROOK, P. H. & SHAW, W. C. 1989. The development of an index
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CUTRESS, T. W., AINAMO, J. & SARDO-INFIRRI, J. 1987. The ing): reliability and validity. Eur J Orthod, 14, 125-39.
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DANIELS, C. & RICHMOND, S. 2000. The development of the
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70 Orthodontic Indices
6
Orthodontic
Anchorage
Written by: Mohammed Almuzian, Haris Khan, Farhana Umer
In this Chapter
1. Intra-oral sources of OA
2. Extra-oral sources of OA
3. Terms and principles used with OA
4. Classification of OA
5. Supplementing the OA unit
6. Measuring OA loss
7. OA in three planes
8. Assessment of OA need
9. EXAM NIGHT REVIEW
O rthodontic Anchorage (OA) is the resistance to un-
• Group A or maximum anchorage in which the ante-
rior teeth/ Unit retraction (active unit) moves 75%
wanted reactionary forces during the orthodontic treatment into the extraction site. In comparison, 25% of the
(Proffit et al., 2018). OA should always be planned in 3 planes remaining space is utilised by the protraction of the
of space: anterior-posterior, lateral and vertical (Naish et al., posterior teeth (anchor unit). Thus, the expectation
2015). in this type of anchorage is predominantly the re-
Intra-oral sources of OA traction of the anterior teeth.
• Labial musculature (OA is derived from the action • Absolute Anchorage where the posterior teeth pro-
of muscles such as a lip bumper) tract minimally (less than 1mm). Hence, posterior
teeth position is essentially maintained.
Extra-oral sources of OA
B. According to the number of teeth/type of movement in-
These include: cluding:
• Cranium • Simple OA refers to one tooth providing anchorage
• Forehead to another tooth.
• Neck • Compound OA refers to a group of teeth providing
anchorage to one tooth or a smaller number of teeth.
• Chin
• Reciprocal OA refers to an equal force applied to
Terms and principles used with OA. teeth of similar anchorage value (RSA) that causes
OA loss is the undesired movement of the anchor units equal movement towards/away from each other, for
during orthodontic treatment. OA burn (planned loss) is example, symmetrical arch expansion or closing a
performed when occlusal objectives are achieved, and the midline diastema.
aim is to close residual spaces. Each tooth’s root surface • Stationary OA is achieved by allowing the active unit
area (RSA) is proportional to its anchorage value. Greater to tip against bodily resistance of the reactive (an-
resistance has been provided with increased RSA (Hixon et chor unit)
al., 1970). However, the relationship between RSA and tooth
movement is not linear. Therefore, other factors are involved • Differential OA represents staged tooth movement
in (Pilon et al., 1996). The rate of tooth movement (RTM) to reduce anchorage demand/taxing, such as tipping
is related to force per unit RSA “differential force theory” the active unit first then uprighting it. The Differen-
(Baumrind et al., 1984). Large individual variation exists in tial force theory involves a combination of station-
the RTM for a particular force applied (Dudic et al., 2013). ary and differential OA.
Maximum RTM could be achieved with forces ranging from C. According to the source and the involved jaws, including:
104-454gm (Ren et al., 2004). RTM increases with increased
applied force, but only up to a point (Quinn and Yoshikawa, • Intraoral orthodontic anchorage such as intramaxillary
1985). and intermaxillary OA. An example of intermaxillary
OA is Class II myofunctional appliances that utilise the
Classification of OA oral muscle’s force. Another example is the intermaxillary
OA relates to all three planes of space and can be gained elastics which relies on the opposite arch to provide OA.
from intra-oral and extra-oral sources. However, prolonged use can lead to excessive extrusion,
canting the occlusal plane, and tipping the anterior teeth.
A. According to the amount of movement of the anchor unit
(Nanda and Burstone, 1993) including: • Extraoral orthodontic anchorage includes head-
gear (HG) or a protraction facemask (PFM).
72 Orthodontic Anchorage
• Soft tissue borne OA which is obtained from: 2. Bracket Type / Prescription: Standard edgewise appliances
preserve around 0.8mm of OA compared with straight wire
1. Palatal vault: OA can be obtained through contact-
appliances (SWA) in the maxillary arch; this may be due to
ing the palate and using this interaction to resist
SWA achieving greater torque and straining anchorage units
tooth movement, e.g. upper removable appliance or
than SEA (Lotzof et al., 1996). TipEdge appliances that uti-
Nance appliance.
lise the differential force theory preserve more OA (0.6mm)
2. Lip Bumper: The muscular forces of the displaced than SWA, though this is not a clinically significant (Usmani
lower lip are transferred to the molars through lip et al., 2002). Theoretically, MBT brackets are associated with
pads and heavy wire attached to the molars; this re- minimal OA due to reduced tip compared with the Roth sys-
sults in molar anchorage reinforcement, uprighting tem. Moreover, the increased molar buccal root torque in the
and distalisation. MBT prescription reinforces anchorage via the cortical bone
theory. On the other hand, some propose that lower torque
• Bone borne OA which is obtained from:
in the Roth prescription preserves OA compared with MBT.
1. Palatal arch, Nance, Lingual arch (Rebellato et al.,
3. Biomechanical factors: The use of low force magnitude
1997) generate OA by relying on the cortical an-
and archwire bends such as toe-in (1st order) and tip-back
chorage theory. Cortical anchorage theory is based
(2nd order) bends could help preserve OA. Stopped archwire
on the principle that the cortical bone resorbs slow-
such as crimpable stops mesial to the first molar and utility
er than medullary bone; therefore, a slower rate of
arches can be used to prevent mesial movement of the molar.
movement occurs when the roots of posterior teeth
However, this approach can be at the expense of the proclina-
contact cortical bone while moving buccally, hence,
tion of incisors. They are pushing mechanics that preserves
increasing OA value. However, in a clinical study, the
OA compared with pulling mechanics at the cost of procli-
palatal arch was found to have a minimal increase in
nation of the anterior segment. Theoretically, Laceback pre-
OA benefit (Zablocki et al., 2008). An RCT found
serves OA by maintaining the arch length. However, it was
no clinical significance between a palatal arch and
concluded that there are no differences in overall OA loss,
Nance appliance in terms of OA loss though patients
anterioposterior and vertical changes of the lower incisors
prefer a palatal arch over a Nance appliance (Stivaros
secondary to the use of Laceback (Irvine et al., 2004). Lace-
et al., 2010). The use of ankylosed teeth is another
backs are effective in maxillary canine retraction with sig-
example of cortical anchorage theory (Kokich et al.,
nificantly less mesial molar movement (Fleming et al., 2013).
1985)
4. Stagged tooth movement while correcting centre lines
2. Bone supported/engaged devices such as implants
by moving one active tooth at a time might minimise me-
/ miniscrews / TADs / plates can provide a direct
sial movement of the molar. Two-stage retraction includes
anchorage (Ismail and Johal, 2002). The orthodon-
retraction of canines followed by retraction of the incisors. A
tic force could be applied directly from the TAD to
systematic review confirmed that both one-stage (en-masse)
one or multiple teeth or indirectly where TAD is
and two-stage retraction are equally effective in space clo-
used to anchor one or multiple teeth in a unit; an
sure with minimal difference in AO (Sueri and Turk, 2006).
orthodontic force is then used against this anchor
unit to orthodontically move a segment. An RCT
found no clinically or statistically significant differ-
Measuring OA loss
ences in the effectiveness of 3 methods of anchorage
supplementation (TADs, Nance and HG). Hence, OA loss is assessed by comparison of tooth position relative
patient preferences should be considered (Sandler to a stable structure over time using one of the following
et al., 2014). A systematic review and meta-analysis methods:
showed moderate-quality evidence favouring mini-
1. Cephalometric analysis such as:
screw performance compared with conventional an-
chorage devices (Alharbi et al., 2018). a) Subjective (visual) cephalometric structural analy-
sis using maxillary and mandibular Bjork’s stable structures
Supplementing the OA unit
b) Objective cephalometric analysis using different
These include:
analyses such as:
1. Treatment planning related factors: For example, a plan that
• Lower incisor position about N-Pog or NB or MP:
includes utilising prosthetic implants, if possible, or modifying
the extraction pattern. Extraction of teeth close to the active unit • Pitchfork analysis in which the reference structures
is associated with less OA demand, i.e. first premolar extrac- are the maxilla and zygoma. This analysis mea-
tion instead of second premolar extraction (Naish et al., 2015). sures AP movement of the upper and lower incisors
and molars. However, there is no measurement of
Orthodontic Anchorage 73
changes in incisor inclination or canine angulation 3. Anteroposterior Orthodontic Anchorage (AP): Anchor-
(Rizk et al., 2018). age in the AP plane is reinforced with various appliances, e.g.
Nance appliance, palatal arch, headgear, upper removable ap-
• Pancherz technique measures the linear changes
pliance, or miniscrews.
from a perpendicular drawn from Sella to the occlu-
sal line. However, this method depends on maxillary Assessment of OA need
structures and the occlusal plane, which are subject
Several factors conjointly play a role in determining the OA
to change.
requirement, including:
2. The intraoral photograph is mainly a subjective visual
1. General factors include age, medical condition, individu-
technique.
al variation and patient compliance.
3. Study model measurement by superimposing 3D models
2. Treatment plan factors such as:
on the palatal rugae. This method is becoming widely used
with developments in the digital imaging (Johnston, 1996). • Treatment aims and the amount of anterior teeth re-
The palatal rugae are a reliable structure for superimposition traction compared to posterior protraction.
with a margin of error of +0.8mm (SD). Therefore, changes
• Type of movement required as the anchorage de-
less than 1.6mm are unlikely to be statistically significant
mand is high for bodily movement compared to tip-
(Sandler et al., 2014).
ping movements (Hoggan and Sadowsky, 2001).
4. Direct clinical assessment by assessing the changes in oc-
• Extraction pattern as the anchorage demand is pro-
clusal relationships, especially if one arch remains untreated
portional to the position of the extracted tooth.
as a baseline.
3. An intra-arch relationship such as:
OA in three planes
a) The involved arch, as the maxillary arch, is mainly are
Orthodontic forces are applied in vertical, transverse, and
more prone to OA loss than the mandibular arch; this is
sagittal (AP) planes. Therefore, OA requirements must be
likely due to a combination of factors:
considered in 3 dimensions.
• Maxillary anterior teeth are larger than mandibular
1. Vertical Orthodontic Anchorage: Consideration of ver-
anterior teeth, therefore, having greater root surface
tical OA is essential in treating anterior open bite and deep
area and anchorage demand when they are moved
bite. In anterior deep bite, flattening the COS involves recip-
(Zhu, 2017). Also, the surface area of the roots of
rocal OA through the extrusion of the posterior teeth and
maxillary posterior teeth (in the buccolingual direc-
intrusion of anterior teeth. The second permanent molar
tion not overall) is less than the mandibular poste-
should be bonded/banded to increase anterior intrusion.
rior teeth.
This is thought to increase the vertical OA value of the an-
chorage unit. Therefore, more significant intrusion occurs • Maxillary posterior teeth are usually upright/tipped
in the anterior segment. In an anterior open bite, adding mesially. Hence, they are more susceptible to OA
a compensatory COS in the upper arch intrudes the pos- loss (Alexandros, 2014). Also, the maxillary occlu-
terior teeth when combined with anterior intermaxillary sal plane is usually inclined clockwise with a higher
“box” elastics. This approach is referred to as ‘Kim mechan- anterior force vector than the lower occlusal plane.
ics’. Anterior elastics withstands the intrusive effects of the • The mandibular bone is denser than the maxillary
compensatory curve of Spee imparted by the wire and can bone (upper posterior is less dense than the upper
be considered a type of intermaxillary compound anchorage. anterior, lower alveolar bone is the denser bone)
2. Transverse Orthodontic Anchorage: For bilateral expan- (Geron, 2003, Devlin, 1998).
sion, there are usually an equal number of teeth on both sides, • Most prescriptions have high tip and torque built in
which achieves reciprocal OA. To accomplish a unilateral the upper anterior brackets compared to lower ante-
expansion, the anchorage side (correct side) should have a rior brackets; this is associated with high anchorage
greater number of teeth (compound anchorage), or the ex- demand.
pander is placed closer to the active unit, the side on which
expansion is required. This results in greater force on the • Individual variations (Alikhania, 2018).
active side and a lower force on the anchorage unit. While • Combination of the above.
aligning the palatally placed ectopic canines, an OA demand-
ing in 3 planes of space and mainly in the transverse plane is b) The amount of crowding as severe crowding requires
required. This can be obtained by stabilising the arch with a more OA due to multiple tooth movements.
heavy stainless steel archwire or a palatal arch. c) The location of crowding, the greater the distance be-
74 Orthodontic Anchorage
tween the anchor unit and the displaced active unit/teeth, EXAM NIGHT REVIEW
the greater the OA demand.
Anchorage is the resistance to unwanted reactionary forces
d) Teeth angulation, for instance, distally angulated teeth, during treatment in all three planes of space (Profit, 2000).
have a higher OA demand to align and retract than upright
Intra-oral sources of anchorage
or mesially inclined teeth due to greater root movement be-
ing required. • Cortical alveolar bone.
e) For instance, the incisors’ inclination, retroclined upper • Soft tissue.
incisor in Class II Division 2 cases, requires greater OA to
• Teeth.
torque the upper incisors.
• Basal bone.
4. The inter-arch relationship such as:
• Labial musculature in which the OA is derived from
• The degree of overbite and overjet: Increased over-
the action of muscles via a vestibular shield or lip
bite and overjet require greater OA.
bumper.
• The amount of centerline discrepancy
Extra-oral sources of anchorage
• The severity of skeletal relationship in the antero-
• Occipital.
posterior and vertical direction: It has been proven
that high angle cases have higher OA demands. This • Forehead.
is mainly because the bone in high angle cases is less • Neck.
dense than the bone in low angle cases, favouring
tooth movement and OA loss. Moreover, the orien- • Chin
tation of the occlusal plane in high angle cases fa- Classification of OA
vour the mesial movement of the anchor teeth. A
study showed that the weak muscle fibres of high A. Based on the movement of the anchor unit.
angle cases lead to low occlusal interlocking force B. According to the manner of the force application.
than low-angle cases, facilitating OA loss (Naish et
al., 2015). C. According to the source and the involved jaws.
Orthodontic Anchorage 75
• Pushing mechanics. • Occlusal interlocking.
• Correcting centerlines → one tooth at a time. F. Factors related to the anchorage units:
• Subdivision of the desired movement: A systematic • Root surface area of the anchor units.
review confirmed that both one step (en-masse re-
• Tooth condition and periodontal support.
traction) and two-step methods are effective for
space closure, but the one-step method with TADs
is better in anchorage reinforcement and amount of
Evidence Summary
retraction (Sueri and Turk, 2006).
• An RCT found no significant clinical difference be-
Assessment of anchorage need
tween a palatal arch (Goshgarian) and a Nance ap-
Several factors conjointly play a role in determining the OA pliance in preventing mesial drift or distal tipping.
needs, including: However, palatal arches are associated with reduced
patient discomfort (Stivaros et al., 2010).
A. General factors
• An RCT found no clinical or statistically signifi-
• Age.
cant differences in the effectiveness of 3 methods of
• Medical condition. anchorage supplementation (TADs, Nance palatal
arches and HG). Hence patients preferences should
• Medication.
be considered (Sandler et al., 2014).
• Individual variation.
• An RCT found that the use of laceback ligatures
• Patient compliance. in first premolar extraction cases doesn’t benefit
in controlling both sagittal and vertical position of
B. Treatment plan factors
lower incisors(Irvine et al., 2004).
• Treatment Aims.
• An RCT found that lacebacks do not prevent ULS
• Type of movement required (Rizk et al., 2018). proclination or molar position. The amount of ULS
• Extraction pattern. proclination depends on the angulation of the ca-
nine, and the laceback makes no difference (Usmani
C. Treatment mechanics factors et al., 2002).
• Appliance prescription: MBT has less anchorage de- • According to a systematic review and meta-analysis,
mand no evidence was found that Lacebacks effectively
• Appliance type: Tip-Edge appliance has a reduced control the sagittal position of incisors during the
anchorage demand alignment phase (Fleming et al., 2013).
• Upper removable appliance lower anchorage de- • A systematic review confirmed that both one-step
mand than a fixed appliance. and two-step retraction methods are effective for
space closure. Still, the one-step method with TAD
D. Intra-arch relationship anchorage is better in anchorage reinforcement and
• Involved arch: Maxillary arch susceptible to OA loss. the retraction (Rizk et al., 2018).
• Amount of crowding.
• Location of crowding.
• Tooth angulation.
• The inclination of the incisors
E. Inter-arch relationship
• Overbite.
• Overjet.
• Centerline discrepancy.
• A-P Skeletal relationship.
• Vertical Skeletal relationship.
76 Orthodontic Anchorage
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Orthodontic Anchorage 77
7
TEMPORARY ANCHORAGE
DEVICES
Written by: Mohammed Almuzian, Haris Khan, Ahmed M. A. Mohamed, Zahid Majeed
In this Chapter
1. A brief history of TADs 15. Special features in the TADs
2. Design features of TADs 16. How to optimise the success rate of TADs?
3. Characteristics for ideal TADs 17. Post-operative instructions
4. Osseointegrating screws 18. Direct versus indirect anchorage
5. Types of osseointegrating screws 19. Bicortical anchorage
6. Mechanically retained screws 20. Complications associated with TADs
7. Design features of miniscrews 21. EXAM NIGHT REVIEW
8. Indications of TADs
9. Contraindications and limitations of TADs
10. Advantages of TADs
11. Disadvantages of TADs
12. Stability and failure of TADs
13. Factors affecting failure of TADs
14. The failure rate of TADs according to the site of
insertion
A temporary anchorage device (TAD) is temporarily fixed
• Versatile and convenient for insertion in a wide va-
riety of sites without damage to adjacent vital struc-
to the bone to enhance orthodontic anchorage. TADs are also tures (e.g. teeth)
known as temporary intraoral skeletal anchorage devices
(TISADs), ortho implants, mini-implant, microimplant (MI), • Convenient for application of orthodontic forces by
miniscrew, microscrew (MS) or orthodontic pins (Cope, J.B. a variety of means and in a variety of directions
2005). TADs provide anchorage either by supporting the Osseointegrating screws
teeth of the reactive unit (indirect anchorage) or by obviating
Osseointegration is the direct structural and functional con-
the need for the reactive unit altogether (indirect anchorage)
nection between living bone and a load-bearing artificial
(Alharbi, F., Almuzian, M., et al. 2018).
implant (Albrektsson, T., Brånemark, P.-I., et al. 1981). Os-
TADs differ from conventional dental implants, which sup- seo-integrating anchorage devices require surgical removal
port a prosthesis. Although traditional dental implants may following use. Osseointegrating screws can withstand high
be used for orthodontic anchorage, they are not considered forces and can provide absolute anchorage. However, osseo-
as temporary anchorage devices as they are not removed after integrating screws are required traumatic insertion and re-
the orthodontic treatment (Singh, K., Kumar, D., et al. 2010). moval as a surgical procedure are needed. Apart from specific
A brief history of TADs circumstances where immediate loading is feasible, there is
an increased waiting period before loading is mandatory (at
Osseointegrating titanium implants were first described in least 12 weeks) (Esposito, M., Grusovin, M.G., et al. 2013).
1969 (Branemark, P.I., Adell, R., et al. 1969). Vitalium im-
plants used to correct increased overbites were reported in Types of osseointegrating screws
1983 (Creekmore, T.D. and Eklund, M.K. 1983). In 1997 first These include:
titanium miniscrews was described by Kanomi (Kanomi, R.
1. Mid-palatal implants are usually supplied as cylin-
1997), and in 1999, the first mini-plate were used for orth-
drical implants with 4 to 6 mm (mostly 6) length (Wehrbein,
odontic purposes (Umemori, M., Sugawara, J., et al. 1999).
H., Feifel, H., et al. 1999) and 3-4 mm in diameter: (Tins-
Design features of TADs ley, D., O’Dwyer, J., et al. 2004). The mid-palatal implant is
These include: usually inserted 6 to 9 mm posterior to the incisive foramen
posterior to the interconnecting line of the first premolars
• Based on the materials used (Singh, K., Kumar, D., et (Kinner, F. and Schlegel, K.D. 2002). They are placed in the
al. 2010), this includes Biotolerant (stainless steel, chro- anterior palatal vault(Tinsley, D., O’Dwyer, J., et al. 2004).
mium-cobalt alloy), Bioinert (titanium alloy, pure tita- It is recommended to avoid midpalatal insertion in patients
nium, carbon) and Bioactive (hydroxylapatite, ceramic below 17 due to the high risk of failure as the suture is im-
oxidised aluminium). mature (Bernhart, T., Vollgruber, A., et al. 2000). Mid-pal-
• Based on diameter: The diameter usually ranges from 1.0 atal implants are used for distalization of molars, enmass
to 2.0 mm. reaching 3 to 4 mm in the palatal implants retraction of the anterior segment and protraction of poste-
(Mizrahi, E. and Mizrahi, B. 2007). rior teeth. The main advantages of mid-palatal implants are:
• Based on length: The length of a TAD refers to the length • It withstands greater orthodontic forces.
of the threaded body. They are typically available in 6, 8, • It provides almost absolute anchorage.
10, and 12 mm but range from 4 to 21 mm.
• It is placed away from the roots of teeth.
• Other design features such as thread depth, thread de-
sign, pitch (number of threads), taper (conical vs cylin- • High success rate, up to 89.5% (Schätzle, M., Män-
drical), flute (fluted vs not fluted), head design and pre- nchen, R., et al. 2009)
drilling vs self-drilling. While the disadvantages of mid-palatal implants are:
Characteristics for ideal TADs • Higher cost
These include: • Osseointegration means a need for waiting time be-
• Biocompatible fore loading and traumatic removal.
• Low cost • Risk of anterior teeth roots damage if placed too an-
teriorly.
• Acceptable for patients – no discomfort during in-
sertion, use or removal • There is a high failure rate in the mid-palatal suture
(Bernhart, T., Vollgruber, A., et al. 2000).
• Accept direct and indirect loading of force
2. Onplants are subperiosteal titanium alloy disks
In this Chapter
1. Why do we take teeth out? 14. Lower second molar extraction
2. Claimed advantages of the non-extraction ap 15. Upper central incisor extraction
proach 16. Upper lateral incisor extraction
3. Claimed advantages of extraction approach 17. Upper canine extraction
4. Prevalence of extractions in orthodontics 18. Upper first premolars extraction
5. Evidence about the detrimental effects of extrac 19. Upper second premolar extraction
tion
20. Upper first molar extraction
6. Extraction of primary teeth
21. Upper second molar extraction
7. Guidelines for extraction of primary teeth
22. Third molars extraction
8. Extraction of permanent teeth
23. EXAM NIGHT REVIEW
9. Lower incisor extraction
10. Lower canine extraction
11. Lower first premolars extraction
12. Lower second premolars extraction
13. Lower first molar extraction
D r Wolf, the physiologist, stated that bone formation was
•
•
Less iatrogenic impact on the vertical relationship
Less iatrogenic effect on smile width
related to its stress. Dr Angle assumed that bone could sur-
round teeth and stabilise them in their new functional po-
sition. Dr Angle was convinced that the human jaw could
Claimed advantages of extraction approach
accommodate a full set of teeth in an ideal occlusion. Dr
Angle was also very preoccupied with facial aesthetics and These include:
maintaining the ideal profile, which could be gained from
• Controllable outcomes
the ideal positioning of a full complement of teeth. Calvin
S. Case criticises Dr Angle for his non-extraction approach • Improved stability
since it influences the profile (Bernstein, 1992a, Bernstein,
• Reduces the protrusive facial appearance
1992b). Around the 1930s, Charles Tweed and Raymond
Begg, both ex-pupils of Angle, were simultaneously revising • Minimal gingival recession
their therapies to include extractions after being dissatisfied • Tooth size reduction is required to compensate for a
with the extent of relapse noted in previous non-extraction dietary change.
cases. Raymond Begg abandons non-extraction due to high
relapse and accused the loss of interproximal abrasion for the Prevalence of extractions in orthodontics
need for extraction. McCaul (McCaul et al., 2001) found that extraction for orth-
odontic purposes represents 10% of overall extraction in
dentistry. Weintraub (Weintraub et al., 1989) found that the
Why do we take teeth out? actual extraction rate is 54% in all orthodontic treatments.
These include: He also found a wide variation in extractions that had no as-
sociation with the year of graduation. Bradbury (Bradbury,
• General factors like caries, periodontal problems, or
1985) surveyed the teeth extracted by orthodontists in a hos-
severe malposition
pital setting. The first premolars were the teeth most com-
• Relief of arch length discrepancy monly extracted tooth (59%), followed by the second premo-
lars (13%), first permanent molars (12%), second permanent
• Correction of incisor relationships and overjet
molars (7%), permanent canines (4%), permanent lateral in-
• For correction of overbite (flattening of the curve of cisors (3%) and the permanent central incisors (1%).
Spee requires space)
Evidence about the detrimental effects of extraction
• Reduce the fullness of the lip, e.g., Bimaxillary pro-
These include:
trusion
1. Profile: There is a long debate regarding the effects of
• Correction of midline shift of more than 4mm.
extraction on facial profiles. Several comparative studies
• Allow molar distalization (Drobocky and Smith, 1989, Luppanapornlarp and Johnston,
1993, Bishara et al., 1997, Paquette et al., 1992, Bowman and
• Management of tooth size discrepancy
Johnston, 2000) proved that extraction changes facial profile.
• Provision of anchorage provision and allow the use Other studies (Boley et al., 1998, Staggers, 1990, Rathod et
of intermaxillary elastic al., 2015, Zierhut et al., 2000) contradict these findings. A
• Interceptive orthodontic treatment systematic review (Iared et al., 2017) compared premolar ex-
traction versus non-extraction groups and found no signifi-
• Enhance stability (weak evidence) cant differences between the groups in terms of the aesthetic
Claimed advantages of the non-extraction approach outcomes. According to another systematic review (Leonardi
et al., 2010), there is a significant individual variation re-
These include: sponse, and the effects of extraction are small on facial pro-
• Less trauma to the child file. Another review (Konstantonis et al., 2018) showed that
extraction seems to affect facial profile, but the evidence is
• Ease of treatment low quality.
• Consumer demand 2. Smile width: Orthodontic treatment involving extrac-
• Short treatment duration tions has been accused of causing a larger “dark buccal cor-
ridor”, though this claim has been rejected by Johnson and
• Facial fullness gives a youthful profile Smith (Johnson and Smith, 1995) and a systematic review
• Less iatrogenic effect on TMJ (Christou et al., 2019) which concluded that extractions do
92 Extraction In Orthodontics
not affect the smile width and buccal corridors area. 7. The outcome of treatment: Ileri (Ileri et al., 2012) ret-
rospectively compared the outcome in treating Class I with
3. Vertical Dimension: Dewel (Dewel, 1967) expressed
the extraction of 4s, non-extraction, or extraction of single
worries that premolar extraction may tend to deepen the bite,
incisors. They found that the outcome measured on the PAR
cause lower incisors to tip lingually, and lead to TMD devel-
basis was better in non-extraction groups.
opment. On the other hand, Beit (Beit et al., 2017) found that
extraction results in a slight decrease in vertical dimension 8. General problems such as extra cost, pain, bleeding,
while non-extraction treatment increase vertical dimension. infection, prolonged treatment, difficulty to close spaces,
Paquette (Paquette et al., 1992) found no convincing stud- intra-oral detrimental effects like potential teeth size discrep-
ies that suggest that vertical dimension is influenced by ex- ancy
traction or non-extraction treatment. Similar findings were
Extraction of Specific teeth
reported by Alkumru (Alkumru et al., 2007). According to
a systematic review (Kouvelis et al., 2018), orthodontic treat- The factors that should be kept in mind before planning
ment with premolar extractions has minimal effect on the extraction in orthodontic cases are:
vertical dimension.
• Tooth-arch discrepancy: Overall, tooth material ex-
4. TMD: It has been suggested that removal of four premo- cess should be determined before planning extrac-
lar teeth before orthodontic treatment can be detrimental to tions in orthodontic cases.
the orthopaedic stability of the temporomandibular joint as
• Cephalometric discrepancy: Before planning ex-
a result of “over retraction” of the maxillary incisors during
traction, the orthodontist should consider the pa-
space closure, which displaces the mandible posteriorly (Far-
tient profile, which could be affected by tooth move-
rar and McCarty, 1982). On the other hand, Kim and col-
ment after extractions. Studies have shown that for
leagues (Kim et al., 2002) showed that orthodontic treatment
each 1 mm of retraction of the upper incisor, the up-
has little to do with TMDs. According to a Cochrane review
per lip could retract by up to 0.3-0.75 mm (Ramos et
(Luther et al., 2010, Luther et al., 2016), there are insufficient
al., 2005). Regarding the lower lip, for every 1 mm of
research data to base our clinical practice on the relationship
lower incisor retraction, the lower lip retracts by 0.6
of active orthodontic intervention and TMD. At present, the
mm-0.78 mm (Kusnoto and Kusnoto, 2001).
Cochrane evidence on TMD and orthodontic treatment have
been withdrawn. • Dental asymmetry: Studies have shown that max-
illary midline deviation from facial midline can be
5. Effect on the periodontium: Artun (Årtun et al., 1987)
accepted aesthetically if the difference is not remark-
showed that excessive proclination of mandibular incisors
ably great. According to research, the mean clinical
might lead to dehiscence, and the overlying gingiva will be-
threshold for acceptable dental midline deviation is
come very thin and more susceptible to recession than thick
2.2 +/- 1.5 mm (Beyer and Lindauer, 1998). Another
attached gingivae. According to a systematic review by Aziz
systematic review (Janson et al., 2011) showed that
(Aziz and Flores-Mir, 2011), there is some association be-
dental midline deviation of 2.2 mm is considered
tween appliance induced labial movement of mandibular in-
acceptable by both orthodontists and laypeople,
cisors and gingival recession in the presence of the following
whereas the axial midline angulation should be less
risk factors:
than 10°. Therefore, evaluating the midline as a sign
• A reduced free gingival margin thickness of dental asymmetry is one of the major concerns
before planning tooth extractions. Patients present-
• Inadequate plaque control
ing with severe dental midline deviation to the face
• Aggressive tooth brushing (especially in the lower arch) and arch length dis-
crepancy might require asymmetrical teeth extrac-
• Narrow mandibular symphysis
tions.
6. Stability and relapse: Some clinicians argue that extrac-
• Pathologies: Some pathologies play a crucial role in
tions minimise relapse. However, it has been shown that
defining orthodontic treatment planning. If teeth
relapse can happen equally in extraction and non-extraction
have periodontal problems, abnormal shapes, roots,
cases (Little, 1990). Paquette (Paquette et al., 1992) reported
and other pathologies, they should be included in
that the Little index in the lower labial segment at recall visits
the extraction pattern.
was 2.9 mm in the extraction group and 3.4 mm in the non-
extraction group. This difference was not significant. Hoyb- Extraction of primary teeth
jerg et al. (Hoybjerg et al., 2013) showed that using different
• When an orthodontist is dealing with enforced
retention regimes in extraction or non-extraction cases has
extraction of a deciduous tooth, a treatment plan
similar stability outcomes.
should be made whether to remove the unsavable
Extraction In Orthodontics 93
tooth, extract a contralateral tooth from the same duced overbite, increased inter-canine width, distal
arch (balance), or extract a tooth from the opposing tipping of the canines, minor crowding and tooth
arch (compensation). excess in the lower arch may justify lower incisor ex-
traction (Zhylich and Suri, 2011, Faerovig and Zach-
• Balancing extraction refers to removing a tooth from
risson, 1999).
the opposite side of the same arch; it is designed to
minimise centerline shift. Compensating extraction • Class I malocclusion with a well-aligned upper arch,
refers to removing a tooth from the opposing quad- good intercuspation in the buccal segment but local-
rant to maintain the buccal occlusion by allowing ised lower incisor crowding (Faerovig and Zachris-
molar teeth to drift forwards in unison. son, 1999). In such cases, it has been reported that
single incisor extrcation is asscoiated with reduced
Guidelines for extraction of primary teeth
treatment duration comapred to premolars extrac-
Before planning extraction of primary teeth, it is essential to tion (DiBiase et al., 2011) and reduced anchorage
undertake a thorough radiographical examination to assess demand due to the locked posterior occlusion.
the presence, position, and formation of the developing
• Class II malocclusion with full unit class II molar
permanent dentition.
relationship, increased overjet, and severe upper
• Primary incisor: Early loss of primary incisors has and lower arch crowding that need extraction. These
little effect on the developing permanent dentition, cases can be treated with upper premolar extraction
so it is unnecessary to balance or compensate for the and single lower incisor extraction. Studies suggest
loss of a primary incisor. that in such patients, the long term stability is better
than the traditional four premolars extraction (Lv et
• Primary canine: Early unilateral loss of a primary
al., 2010).
canine can result in centerlines deviation, especially
in crowding in the arch, which necessitates the need Contraindications for lower incisor extraction (Hegarty and
for balancing extraction. Hegarty, 1999)
• First Primary molar: A balancing extraction may These include:
be needed if the loss is unilateral, specifically in a
• Excessive overbite and overjet.
crowded arch. If mandibular first deciduous molars
are lost, some consideration can be given to com- • Poor buccal segment relationship.
pensating extractions in the maxillary arch to pre-
• Patients are having mesially angulated canines.
serve the buccal segment relationship.
• Poor prognosis of posterior teeth.
• Second primary molar: Balancing the loss of a pri-
mary second molar is not indicated because it has no Problems associated with lower incisor extractions
appreciable effect on the centerline. However, if they
These include:
are lost bilaterally in the upper or lower arch, it can
alter the molar relationship; hence, in these cases, • Reduced lower intercanine width.
compensating extractions may be considered. • Lower midline discripnacy due to asymmetric ex-
Extraction of permanent teeth traction.
1. Lower incisor extraction • Increases in the overbite and overjet.
Indications for lower incisor extraction • Needs for fixed appliance therapy to allow con-
trolled bodily movement of the incisors.
These include:
• Difficulty in achieving a good occlusal fit.
• Signficant tooth size discrepancy (TSD) with man-
dibular tooth size excess (Matsumoto et al., 2010). • High risk of space reopening (Dacre, 1985).
• In the presence of poor prognosis of lower incisor • Post-treatment black triangle due to loss of the in-
such as a periapical lesion, bony defects, severe gin- terdental papilla which can be managed by (a) off-
gival recession, heavy restoration, trauma, lost vi- setting the brackets adjacent to the extraction site to
tality, ectopically erupted or impacted incisor and indcue mesial tipping of the roots and (b) wire bend-
abnormal shapes and size such as macrodontia and ing or (c) root uprighting springs.
microdontia (Bahreman, 1977, Canut, 1996, Kokich • Iatrogenic TSD, hence, Bolton’s analysis is essential
and Shapiro, 1984) to be undertaken before extraction. TSD can be
• Mild Class III malocclusion combined with a re- managed by (a) performing upper IPR, (b) sawp-
94 Extraction In Orthodontics
ping upper canine brackets, (c) using low torque • To correct molar relationship and posterior crowd-
upper anterior brackets, (d) inverting lower incisors ing.
brackets, (e) using lower canine brackets with Roth
• Balancing extraction in cases with developmentally
prescription and (f) using Class II elastics.
missing lower second premolars.
• Extraction of a mandibular second premolar is as-
2. Lower canine extraction sociated with rapid space closure, so in theory, it has
minimal effect on profile in patients with a flat pro-
The mandibular canine is rarely extracted because it has a
file.
very good length and is functionally and aesthetically sig-
nificant. However, an extraction might be considered if it is
ectopically eruption, hypoplastic or periodontally compro-
5. Lower first molar extraction
mised with grade III mobility.
Indications for first molar extraction
These include:
3. Lower first premolars extraction
In certain orthodontic cases, extraction of lower first molar
Indications for lower first premolars extraction
is necessary, but before planning extraction of poor prog-
These include: nosis lower first molars, certain factors should be kept in
mind such as the age of the patient, inter arch relationship,
• First, premolars are the most frequently extracted
developmental status, and inclination of the second molars,
teeth in orthodontic cases because they allow bal-
presence, and condition of other teeth and angulation of the
anced posterior anchorage and help in maximum
second premolars.
retraction of anterior teeth (Bradbury 1985).
Indications of lower first molars
• In patients with Class I malocclusions with upper
and lower arch crowding. These include:
• In patients with Class II molar relationship, severe • Extensive caries or pathologies. For details, read the
lower arch crowding and decreased overjet. chapter of the first molar of poor prognosis.
• In patients with Class III molar relationship, mild • Hypoplastic molars- linked with molar incisor hy-
upper arch crowding and reverse or reduced overjet. poplasia.
• Extraction of premolars can be part of the serial ex- • Heavy restoration.
tractions plan.
• In high-angle cases.
• Contraindications for extractions
• Sometimes extraction of the lower first molar may
• These include: be prescribed to prevent the impaction of the third
molar and therefore create space for their eruption
• Risk of excessive lingual movement of lower incisors
(Bayram et al., 2009).
• Mild crowding in the lower arch
Contraindications for first molar extraction
• When other teeth also have a poor prognosis.
These include:
• Third molars are congenitally missing.
4. Lower second premolars extraction
6. Lower second molar extraction
Indications for for lower second premolars extraction
Indications for second molar extraction
These include:
These include:
• Lower premolars with hypoplasia, pathology, peri-
Lower second molars are rarely extracted for orthodontic
odontally involved or ectopically erupted.
purposes; however, in some circumstances, their extraction
• To relieve mild-moderate crowding in the lower is indicated such as:
arch.
• When they are severely displaced.
• To avoid excessive lingual movement of lower inci-
• When they have hypoplasia, they are heavily re-
sors.
stored or have a poor prognosis.
Extraction In Orthodontics 95
• Sometimes their extraction is undertaken to relieve • If maxillary central incisor and maxillary canine are
crowding in posterior teeth such as premolar crowd- in good contact, but lateral incisor is blocked out.
ing or if the premolar is vertically impacted in the
• Upper lateral incisor with severe hypoplasia.
line of the arch (Kenrad et al., 2011).
• Abnormalities in shape and size, such as peg-shaped
• Minimal crowding is present.
lateral incisor.
Contraindications for second molar extraction
• Root resorption due to ectopic eruption of maxillary
These include: canines.
• Third molars are developmentally absent • Severe ectopic eruption of the lateral incisor.
• Lower anterior crowding is greater than 1-2mm. • When the contralateral lateral incisor is develop-
mentally absent.
Advantages of second molar extraction (Bishara SE & Bur-
key P 1986) Contraindications for for upper lateral incisor extraction
These include: These include:
• Reduce the need to extract 3rd molar surgically. • If the crown of the canine is bulbous, than the cen-
tral incisor.
• Limit the morbidity associated with lower third
molar extraction. • When the shade of the upper canine is significantly
dark.
Disadvantages of second molar extraction
• When the gingival margin height of the maxillary
These include:
canine differs considerably from the upper central
• The third molar can erupt into an undesired posi- incisor.
tion (Gooris et al., 1990). Hence, a mechanical erup-
• In Class III incisal relationship.
tion of the third molar using fixed appliance therapy
might be required (Orton and Jones, 1987). 9. Upper canine extraction
• Much research has been conducted for the unsat- Indications for upper canine extraction
isfactory eruption of 3rd molars secondary to the
The maxillary canine is rarely extracted because it is func-
extraction of second molars with a wide range of
tionally and aesthetically significant. Here are some indica-
discrepancies ranging from 2-4% (Cryer, 1967)
tions for extraction of maxillary canine:
(Richardson and Richardson, 1993) to 20% (Dacre,
1987). • If maxillary lateral incisor and maxillary first pre-
molar are in good contact, the upper canine is se-
7. Upper central incisor extraction
verely displaced from the arch line.
Extraction of the central incisor is uncommon in orthodon-
• If the upper canine is ectopically erupted and unfa-
tics, but there are some situations where its extraction can be
vourable for alignment (sector 5, alpha angle greater
considered. Before planning its extraction, an orthodontist
than 55) in this case, its extraction is indicated.
should plan the replacement therapies for the extraction
space. In most cases, lateral incisors can be substituted in • If the maxillary canine undergoes some pathology
their place. Space can also be replaced with implant, pros- with a poor prognosis or abnormal shape.
thesis or transplant (Amos et al., 2009). The indications for
• When the patient is unwilling to consider a long
upper central incisor extraction are:
treatment time to align an impacted canine.
• Poor prognosis, including hypoplasia, caries or trau-
10. Upper first premolars extraction
ma (Bishara SE & Burkey P 1986).
Indications for upper first premolars extraction
• When the upper central incisors are malformed.
The first premolars are considered to be one of the most
• When upper central incisors have severe displace-
commonly extracted teeth in orthodontics (59% of overall
ment.
extraction for orthodontic purposes), followed by sec-
8. Upper lateral incisor extraction ond premolars (13%) and first permanent molars (19%).
The high percentage of first premolar extraction is related
Indications for upper lateral incisor extraction
to its position in the arch and the timing of its eruption.
These include: Moreover, its extraction is well accepted in treating cases
96 Extraction In Orthodontics
of malocclusion that include severe crowding, unilateral
agenesis, bimaxillary protrusion, convex facial profiles, and • In Class II surgical cases, extraction of upper second
large cephalometric discrepancies in borderline cases. The and lower first premolars are done to aid in decom-
benefits of first premolar extraction are that second premo- pensation of the arches.
lars easily substitute them from aesthetic and functional • In cases where lower premolar extraction is advised,
points of view. A good contact point is established between lower 8s are missing. Upper 2nd premolars are ex-
the canine and second premolar. Another advantage of first tracted to prevent extrusion of upper 7s.
premolar extraction is that good anchorage balance is easily
• If there is good interproximal contact between the
achieved.
upper first premolar and the molar, then a maxillary
The following are indications for maxillary first premolar second premolar is recommended.
extraction:
12. Upper first molar extraction
• When upper first premolar has hypoplasia, severely
Indication for upper first molar extraction
displaced, transposition cases and has a poor prog-
nosis. These include:
• The first premolar is often ideal in relieving anterior • If the upper first molar is carious, it has hypoplasia
and posterior crowding. or large restoration.
• As part of the serial extractions plan. • As compensation for the removal of the lower first
molar.
• Midline correction.
• To relieve posterior crowding.
• Correction of overjet.
13. Upper second molar extraction
• Anchorage balance.
Indications for upper second molar extraction
• Correction of incisor inclination.
These include:
• For levelling of the curve of Spee.
• To aid the distal movement of the upper buccal seg-
• For surgical decompensation. ments with extraoral traction.
11. Upper second premolar extraction • When upper second molars have a poor prognosis,
Indications for upper second premolar extraction grade III mobility or severe hypoplasia.
• If the maxillary second premolar is impacted, hypo- There is a wide range of variation in formation and calcifica-
plastic, small size, heavily restored, or poor progno- tion, crown and root morphology, eruption and presence or
sis. absence of third molars. As third molars erupt, they need to
create space in the alveolar arch, and sometimes, this process
• When the second premolar has severe displace- can lead to crowding in the anterior teeth (Almpani and
ment. Kolokitha, 2015). On the other hand, 13-15% of mandibular
• In patients who have congenitally missing second third molars are congenitally missing or become impacted.
premolars on the contralateral side, extraction is The following are some indications for the extraction of
advocated for symmetry of molar relationship. This third molars.
belief is usually not well accepted. • When they have unrestorable caries or non-treat-
Extraction In Orthodontics 97
able pulpal or periapical pathology. • Primary canine →To prevent centerlines deviation in
crowding which necessitate balancing extraction.
• In case severe chronic periodontal disease results in
bone loss and recurrent pericoronitis. • First Primary molar→Balancing extraction in
crowded arch. Compensating extractions in uppers
• When third molars have external or internal resorp-
to preserve the buccal relationship.
tion.
• Second primary molar→ No need for balancing ex-
• Any pathalogy of follicle including cyst or tumour.
traction, compensating extractions considered.
• When the presence of third molars prevents the
Extraction of permanent teeth
eruption of the second molar.
Indication for lower incisor extraction
• When they cause resorption of the second molars.
• Localised lower arch crowding.
• When the third molar is impeding surgery or recon-
structive jaw surgery. • Poor prognosis
• Mild Class III malocclusion combined with a re-
duced overbite
• Class I Good buccal intercuspation & LLS crowding.
• Full unit class II molars & localised LLS crowding.
Indication for lower canine extraction
Ectopically eruption, hypoplastic or periodontally compro-
EXAM NIGHT REVIEW mised with grade III mobility
Extraction in orthodontics Indication for first premolars extraction
Why do we take teeth out? • Class I malocclusions with crowding.
• General factors like caries, periodontal problems, or • Class II molar relationship, severe lower arch crowd-
sever malposition ing.
• Relief of arch length discrepancy • In patients with Class III molar relationship, mild
• Correction of incisor relationships and overjet upper crowding
98 Extraction In Orthodontics
• Poor prognosis (pathology/ hypoplasia/caries/trau- Indication for the upper first molar extraction
ma.
• Carious/ hypoplasia/ large restoration.
• Malformed.`
• As compensation
• Severe displacement.
• To relieve posterior crowding.
Indication for the upper lateral incisor extraction
Indication for the upper second molar extraction
• U1 & U3 in acceptable contact blocked out U2.
• To facilitate distalizatin
• Severe hypoplasia, abnormalities in shape and size.
• Grade III mobility
• Root resorption by U3
• Severe hypoplasia.
• Ectopically erupted U2
• To facilitate 3rd eruption.
• Absent contralateral U2.
Indication for the third molar extraction
Indication for the upper canine extraction
• Unrestorable caries or non-treatable pulpal or peri-
• If U2 & U4 are in good contact, the upper canine is apical pathology.
severely displaced from the arch line.
• Recurrent pericoronitis.
• U3 ectopically erupted, Sector 5, an alpha angle
• External or internal resorption.
greater than 55 in this case.
• Fracture line through 3rd molar.
• If the maxillary canine undergoes some pathology.
• Follicle including cyst or tumour.
• Unfavourable impacted / abnormal shape.
• Eruption of the second molar is prevented
• Poor prognosis.
• Causing resorption of the second molars.
• Patient unwilling for long treatment
• They are impeding surgery or reconstructive jaw
Indication for the upper first premolars extraction
surgery.
• Hypoplasia, severely displaced, transposition cases
and has a poor prognosis
• As part of serial extractions plan
• Midline correction
• Correction of overjet.
• Anchorage balance
• Correction of incisor inclination
• For levelling of the curve of Spee
• For surgical decompensation References
Indication for the upper second premolars extraction ALKUMRU, P., ERDEM, D. & ALTUG-ATAC, A. T. 2007. Evalu-
ation of changes in the vertical facial dimension with different an-
• Mild anterior crowding/ moderate overjet. chorage systems in extraction and non-extraction subjects treated
by Begg fixed appliances: a retrospective study. Eur J Orthod, 29,
• Prevents over retraction of ULS 508-16.
• Impacted U5 ALMPANI, K. & KOLOKITHA, O. E. 2015. Role of third molars in
• Hypoplastic, heavily restored or have a poor prog- orthodontics. World J Clin Cases, 3, 132-40.
nosis AMOS, M. J., DAY, P. & LITTLEWOOD, S. J. 2009. Autotransplan-
tation of teeth: an overview. Dent Update, 36, 102-4, 107-10, 113.
• Severe displacement.
ÅRTUN, J., KOKICH, V. G. & OSTERBERG, S. K. 1987. Long-
• Missing U5 on contralateral side. term effect of root proximity on periodontal health after orthodon-
• In Class II surgical cases for decompensation. tic treatment. American Journal of Orthodontics and Dentofacial
Orthopedics, 91, 125-130.
• Good contact b/w U4 & U6
Extraction In Orthodontics 99
AZIZ, T. & FLORES-MIR, C. 2011. A systematic review of the as- during orthodontic treatment with extraction of four first premo-
sociation between appliance-induced labial movement of mandibu- lars. Am J Orthod Dentofacial Orthop, 95, 220-30.
lar incisors and gingival recession. Australian orthodontic journal,
FAEROVIG, E. & ZACHRISSON, B. U. 1999. Effects of mandibu-
27, 33.
lar incisor extraction on anterior occlusion in adults with Class
BAHREMAN, A. A. 1977. Lower incisor extraction in orthodontic III malocclusion and reduced overbite. Am J Orthod Dentofacial
treatment. Am J Orthod, 72, 560-7. Orthop, 115, 113-24.
BAYRAM, M., OZER, M. & ARICI, S. 2009. Effects of first molar FARRAR, W. B. & MCCARTY, W. L. 1982. A clinical outline of
extraction on third molar angulation and eruption space. Oral Surg temporomandibular joint diagnosis and treatment, Normandie
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BEIT, P., KONSTANTONIS, D., PAPAGIANNIS, A. & ELIADES, T. GOORIS, C. G., ARTUN, J. & JOONDEPH, D. R. 1990. Eruption
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analysis: cephalometric appraisal and Procrustes superimposition.
HEGARTY, D. J. & HEGARTY, M. 1999. Is lower incisor extraction
Prog Orthod, 18, 44.
treatment a compromise? Dent Update, 26, 117-22.
BERNSTEIN, L. 1992a. Edward H. Angle versus Calvin S. Case:
HOYBJERG, A. J., CURRIER, G. F. & KADIOGLU, O. 2013. Evalu-
extraction versus nonextraction. Historical revisionism. Part II.
ation of 3 retention protocols using the American Board of Ortho-
Am J Orthod Dentofacial Orthop, 102, 546-51.
dontics cast and radiograph evaluation. Am J Orthod Dentofacial
BERNSTEIN, L. 1992b. Edward H. Angle versus Calvin S. Case: Orthop, 144, 16-22.
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IARED, W., KOGA DA SILVA, E. M., IARED, W. & RUFINO
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MACEDO, C. 2017. Esthetic perception of changes in facial profile
BEYER, J. W. & LINDAUER, S. J. 1998. Evaluation of dental mid- resulting from orthodontic treatment with extraction of premolars:
line position. Semin Orthod, 4, 146-52. A systematic review. J Am Dent Assoc, 148, 9-16.
BISHARA SE & BURKEY P 1986, S. M. E. A. R., AJO, 89;415-424. ILERI, Z., BASCIFTCI, F. A., MALKOC, S. & RAMOGLU, S. I.
2012. Comparison of the outcomes of the lower incisor extraction,
BISHARA, S. E., CUMMINS, D. M. & ZAHER, A. R. 1997. Treat-
premolar extraction and non-extraction treatments. Eur J Orthod,
ment and posttreatment changes in patients with Class II, Division
34, 681-5.
1 malocclusion after extraction and nonextraction treatment. Am J
Orthod Dentofacial Orthop, 111, 18-27. JANSON, G., BRANCO, N. C., FERNANDES, T. M., SATHLER,
R., GARIB, D. & LAURIS, J. R. 2011. Influence of orthodontic
BOLEY, J. C., PONTIER, J. P., SMITH, S. & FULBRIGHT, M. 1998.
treatment, midline position, buccal corridor and smile arc on smile
Facial changes in extraction and nonextraction patients. Angle
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Orthod, 68, 539-46.
JOHNSON, D. K. & SMITH, R. J. 1995. Smile esthetics after
BOWMAN, S. J. & JOHNSTON, L. E., JR. 2000. The esthetic
orthodontic treatment with and without extraction of four first
impact of extraction and nonextraction treatments on Caucasian
premolars. Am J Orthod Dentofacial Orthop, 108, 162-7.
patients. Angle Orthod, 70, 3-10.
KENRAD, J., VEDTOFTE, H., ANDREASEN, J. O., KVETNY, M.
BRADBURY, A. J. 1985. A current view on patterns of extraction
J. & KJAER, I. 2011. A retrospective overview of treatment choice
therapy in British health service orthodontics. Br Dent J, 159, 47-
and outcome in 126 cases with arrested eruption of mandibular
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CANUT, J. A. 1996. Mandibular incisor extraction: indications and
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long-term evaluation. Eur J Orthod, 18, 485-9.
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H. 2019. Clinical effectiveness of orthodontic treatment on smile
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CRYER, B. J. D. P. 1967. Third molar eruption and the effect of
KONSTANTONIS, D., VASILEIOU, D., PAPAGEORGIOU, S. N.
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& ELIADES, T. 2018. Soft tissue changes following extraction vs.
DACRE, J. T. 1985. The long term effects of one lower incisor nonextraction orthodontic fixed appliance treatment: a systematic
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DACRE, J. T. 1987. The criteria for lower second molar extraction. KOUVELIS, G., DRITSAS, K., DOULIS, I., KLOUKOS, D. &
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DROBOCKY, O. B. & SMITH, R. J. 1989. Changes in facial profile
In this Chapter
1. Indications of IPR
2. General advice before commencing IPR procedure
3. Methods of IPR
4. Air rotor stripping (ARS)
5. Long term potential side effects of IPR
6. EXAM NIGHT REVIEW
B allard first described Interproximal enamel reduction
(LR, 1980b; Peck and Peck, 1972). Prophylactic IPR can be
prescribed either during the initial alignment phase, imme-
(IPR) in 1944 (Ballard, 1944). IPR involves dental width re- diately after active orthodontic treatment or even 4-6months
duction, anatomic recontouring and protection of the mesial post-treatment (LR, 1980b).
and or distal enamel surfaces of a permanent tooth (Peck and
Peck, 1972). IPR can be performed in deciduous and perma- 4. Interceptive treatment to provide space when extractions
nent teeth. IPR is also called interdental stripping, enamel are not planned (Graber et al., 2012) or to premolarise re-
stripping, proximal reduction, reproximation, enamoplasty, tained primary second molars in cases with missing second
keystoning, enamel approximation and slenderising (Daska- premolars (Graber et al., 2012), hence, achieving Class I mo-
logiannakis, 2000; Peck and Peck, 1972; Rossouw and Tor- lar relationship (Graber et al., 2012).
torella, 2003). Keystoning refers to oblique IPR of the lower 5. Management of black triangles or interdental contact ar-
incisors to prevent rotational relapse (Daskalogiannakis, eas by moving the incisal contact point more apically (Saver,
2000). 2004).
Indications of IPR 6. Management of teeth size discrepancy: IPR can be pre-
These include: scribed to improve intermaxillary interdigitation if the
Bolton discrepancy is beyond the average (Bolton, 1962; Ros-
1. Improvement of the shape and form of teeth (Sarver, souw and Tortorella, 2003).
2011b).
7. Canine reshaping in canines substitution cases.
2. Space provision (LR, 1980b; Peck and Peck, 1975; Sheri-
dan, 1985): Theoretically, IPR can provide up to 8mm of General advice before commencing IPR procedure
space in total. IPR of the posterior segment can provide up IPR should be undertaken sequentially and should be less
to 6.4mm of space (0.8mm/contact x 8 contacts). IPR of the than 50% of interproximal enamel to reduce the risk of car-
anterior segment can provide up to 2.5mm (0.5mm/contact ies, sensitivity, discolouration, transeptal bone loss, and peri-
x 5 contacts). However, it is recommended to undertake a odontal disease (LR, 1980b). Trauma to the gingiva should be
conservative IPR of no more than 4mm (Proffit et al., 2007; avoided. Hence, 0.020-inch wires can be used to protect the
Tuverson, 1980) depending on the tooth shape and size (Tu- gingiva while performing IPR.
verson, 1980). The available spaces from the IPR can be uti-
IPR is mainly carried out from posterior to anterior and distal
lised to manage:
to mesial contact points. Moreover, IPR has limited applica-
• There is a mild degree of incisor proclination, es- tion in poor oral hygiene, tooth hypersensitivity, hypoplastic
pecially in the clear aligner therapy (Graber et al., teeth, teeth with high caries risk, small or narrow teeth and
2012)(Kravitz et al., 2008). teeth with artificial crowns/ veneers (Jarvis, 1990; Zachris-
• Shallow overbite (LR, 1980b). son et al., 2011).
IPR might increase pocket depths (0.5-1.5mm) (LR, 1980a), • Tooth hypersensitivity
lead to an insignificant decrease in the alveolar crest height • Hypoplastic teeth
(LR, 1980a) and reduces transeptal bone thickness due to
closer proximity of the adjacent roots. However, the long- • High caries risk
term effects on the health of periodontium are insignificant • Small or narrow teeth
(Årtun et al., 1987; Jarvis, 1990). It has been proven that
deep IPR might produce deep interproximal col and non- • Artificial crowns/ veneers
keratinised plaque susceptible gingivitis (Jarvis, 1990). Methods of IPR
Moreover, IPR might lead to tooth decay, colour changes, Air-rotor stripping (ARS) using either (Sheridan, 1985).
pulpal damage and sensitivity. Evidence showed that IPR
• Fine tungsten-carbide.
10
Written by: Mohammed Almuzian, Haris Khan, Zahid Majeed
In this Chapter
1. Aetiologies of Class I malocclusion
2. Extra-oral features of Class I malocclusion
3. Intra-oral features of Class I malocclusion
4. Methods of space provision to treat Class I mal-
occlusion
5. EXAM NIGHT REVIEW
T he British Standard Incisor (BSI) classification is based on
lary protrusion, where lip fullness and lips can be
incompetent).
the incisor relationship, while Angle’s classification is based
on the molar relationship. Class I incisor is defined as the in- Intra-oral features of Class I malocclusion
cisal edge of the lower incisors occludes or lies immediately These include:
below the cingulum plateau of the upper incisors. (BSI, 1983).
• The common intra-oral feature is crowding, but
Class I molar is defined as the mesiobuccal cusp of the up-
spacing may also be seen.
per first permanent molar occludes in the buccal groove of
the lower first permanent molar in terms of Angle’s classifica- • Incisors are in Class I relationship, canines and mo-
tion (also termed ‘neutrocclusion’) (Angle, 1899). Andrews’s lars are usually in Class I relationship.
Class I molar relationship has two conditions: firstly, the
• Overjet is usually normal.
distal surface of the distal marginal ridge of the upper first
molar should contact and occlude with the mesial surface • Overbite can be increased, normal, or decreased
of the mesial marginal ridge of the lower second molar (this with an anterior open bite.
is originally from Stoller and was referred to as a Stollerized
• The transverse relationship is usually normal, but a
molar) and secondly, the mesiobuccal cusp of the upper first
crossbite may be present.
permanent molar should occlude in the buccal groove of the
lower first permanent molar. Methods of space provision to treat Class I malocclusion
A Class I malocclusion usually includes a Class I incisor and The authors advocate the use of the acronym (SPEED TRIAL)
molar relationship. Both molar and incisor relationships can to memorise the methods of space provision;
be affected by other dental features and may not be a true • Stripping of the enamel (common).
reflection of the underlying skeletal relationship.
• Proclination of the incisors (common).
Class I malocclusion affects 60% of the Caucasian population
(Todd and Lader, 1991) and 80% of the Arab population (Al • Extraction (common).
Jadidi et al., 2018). • Expansion (common).
Aetiologies of Class I malocclusion • Distalization (mainly in the upper arch and ideally
These include: prescribed before the eruption of the second mo-
lars).
• Evolutionary factors mainly as a trend towards soft
diet leading to lack of attrition and subsequently • Torque, i.e. under torquing (applies for the upper
crowding. incisors only).
• Genetic factors include impacted teeth, congeni- • Rotation correction (applies mainly for the premo-
tally missing teeth and microdontia (spacing). lars and molars).
• Environmental factors, including change in the • Incremental growth (applies when the patient is
muscular balance or equilibrium on the developing growing with an increased overjet). (With the man-
dentition, can lead to crowding and sucking habits dible’s growth, the overjet decreases, which decreas-
may lead to open bite, crossbite, increased vertical es the space requirement for overjet correction.)
dimensions etc. Another factor, trauma, may lead to • Angulation, i.e. under tipping (mainly applied on
crowding due to a change in position of developing upper anterior and lower canine teeth).
tooth buds or tooth impaction and premature loss of
deciduous teeth. • Leeway space (in the late mixed dentition).
Extra-oral features of Class I malocclusion Exam night review
These include: • Angle’s Class I occlusion, Neutrocclusion, MB of
U6 occludes in BG of L6 (rotation, malposition,
• Mostly, mesocephalic head shape. crossbite etc.) (Angle, 1899)
• Skeletally Class I, however, mild Class II or Class III • Andrews’s Class I molar if the distal surface of the
skeletal bases may be seen. distal marginal ridge of U6→ the mesial marginal
• Straight profile. ridge of L7 and the MB cusp of U6→ buccal groove
L6.
• Average vertical proportions.
• Class I incisor relation: Incisor edge of LI occlude
• Soft tissues are usually favourable (except bimaxil-
11
Written by: Mohammed Almuzian, Haris Khan, Awrisha Tariq
In this Chapter
1. Aetiologies of bimaxillary proclination
2. Classification of bimaxillary proclination
3. Features of bimaxillary proclination
4. Treatment of bimaxillary proclination
5. Treatment considerations while managing bi
maxillary proclination
6. Relapse after treating bimaxillary dentoalveolar
proclination
7. Exam night review
B imaxillary Proclination is defined as proclination of both
ternal force on the incisors, resulting in bimaxillary
dentoalveolar proclination.
maxillary and mandibular arches or proclination of upper and
lower incisors that cause procumbent lips (Keating, 1986). • Dental factors (McCann and Burden, 1996): The
Controversy exists over the terminology of bimaxillary den- tooth size-arch length discrepancy can be expressed
toalveolar proclination; some researchers believed the term in the form of proclination of incisors. Teeth with
should be used for prognathic maxillary and mandibular jaws a more forward path of eruption cause bimaxillary
only. The term bimaxillary protrusion has been proposed for dentoalveolar proclination.
prognathic jaws and bimaxillary dentoalveolar proclination • Habits: A tongue thrust habit can result in bimaxil-
for proclined upper and lower teeth to differentiate between lary dentoalveolar proclination in both endogenous
jaws and incisors. Bimaxillary dentoalveolar proclination oc- and adaptive forms.
curs when both maxillary and mandibular incisors have been
• Pathological conditions include Cancrum oris, cere-
proclined relative to dental and cranial bases resulting in pro-
bral palsy, hemangioma and untreated cleft lip with
cumbent soft tissue (Burden 1996).
prognathic premaxilla.
Bimaxillary proclination mainly affects Afro-Caribbean’s
Classification of bimaxillary proclination
(Farrow et al., 1993). It is also common among Arab groups
and Asian (Hussein and Mois, 2007), but it is less prevalent in Bimaxillary proclination is classified according to Interincisal
white Caucasian populations (Keating, 1985). angle and include:
Aetiologies of bimaxillary proclination • Mild =125˚-115˚
Bimaxillary dentoalveolar proclination is usually adapted to • Moderate =115˚-105˚
underlying skeletal and soft tissue patterns. The main aetiolo-
• Severe =<105˚
gies are:
However, the cephalometric values should be considered for
• Skeletal factors: It has mostly a genetic origin (Lam-
each race because bimaxillary proclination in one population
berton et al., 1980).
would be considered normal for other people.
• Lip morphology/position (Naini and Gill, 2008):
Features of bimaxillary proclination
In bimaxillary proclination, lips are often full and
everted. Tongue exerts pressure on the teeth so that These include:
dental arches move forward as they grow. The effect
1. Skeletal features (Carter and Slattery, 1988, Keating, 1985)
of soft tissues abnormality at rest is more than dur-
such as:
ing function.
• Prognathic maxillary and mandibular jaws
• Nasal blockage (Solow and Tallgren, 1976b): Due
to nasal blockage, the patient becomes a mouth • Class I Malocclusion
breather, leading to bimaxillary dentoalveolar pro- • Mild class II malocclusion
clination.
• Short posterior cranial base
• Soft tissue stretching theory (Solow and Kreiborg,
1977, Solow and Tallgren, 1976b): This theory pro- • Small posterior Facial height
poses that airway obstruction leads to a neuromus- • Divergent facial planes with steep mandibular plane
cular feedback mechanism, where patients can’t angle
breathe through the nose due to nasal obstructions
or enlarged adenoids, so they adopt a ‘head-up pos- • Increased FMPA
ture’ with the extension of the neck. This leads to 2. Dental features such as:
stretching of suprahyoid muscles, skin and fascia.
This, in turn, imparts a force on the mandible leading • There is dental proclination in both upper and lower
to a downward posture. The tongue, therefore, occu- arches (Carter and Slattery, 1988). The lower incisor
pies a lower position. There is less internal soft tissue proclination compensates for the ANB difference.
force on the maxillary arch (in the transverse plane). Due to the proclination of the incisor, the overbite
The external force of the cheeks results in a narrower is mostly decreased, and, in some cases, the anterior
maxillary arch, potentially causing a crossbite. At open bite may be present.
the same time, the tongue is positioned forwards to • Both dental arches are larger in length due to the
increase the pharyngeal space to aid breathing. The proclination of teeth resulting in spacing and dia-
forward position of the tongue imparts a greater in- stema.
12
Written by: Mohammed Almuzian, Haris Khan, Zahid Majeed
In this Chapter
1. Incidence of Class II Division 1 malocclusion 12. Favourable features for orthodontics camouflage
2. Aetiology of Class II Division 1 malocclusion 13. Combined orthodontic-surgical approach
3. Features of Class II Division 1 malocclusion 14. Indicators for orthognathic surgery
4. Type of lip behaviour 15. Aetiology of relapse
5. Justifications for early treatment of Class II mal 16. Enhancing the stability of treated Class II Divi
occlusions sion 1 malocclusions
6. Treatment timing for Class II Division 1 maloc 17. EXAM NIGHT REVIEW
clusion
7. Class II growth modification / functional jaw
orthopaedics
8. Effects of Class II functional appliances
9. The proposed advantages of the phase I inter
vention
10. Effectiveness of phase I intervention
11. Orthodontics camouflage to treat Class II Divis
ion 1 malocclusion
C lass II incisor relationship describes a situation where the
•
•
Digit sucking.
Mouth breathing.
incisal edges of the mandibular incisors lie posterior to the
cingulum plateau of the maxillary incisors, the upper inci- • Tongue thrusting
sors are either proclined or have a normal inclination, and the
Features of Class II Division 1 malocclusion
overjet is increased (BSI, 1983).
These include:
Class II molars relationship describes a situation where the
mesiobuccal cusp of the permanent maxillary first molar lies 1. Skeletal Features (Hopkins et al., 1968): A Class II malocclusion
mesial to the buccal groove of the permanent first mandibu- is common on a skeletal Class II base (76% of the cases have skeletal
lar molar. Class II intermediate is defined as a Class II incisor class 2 bases). However, they can be found on a skeletal Class I base
and rarely on a skeletal Class III base. A skeletal Class II relationship
relationship with an increased overjet (5-7mm) with upright
is mainly due to mandibular retrognathia (75%) and less commonly
upper incisors. In contrast, Class II indefinite is defined as due to a prognathic maxilla (25%). Retro-positioning of the man-
one upper central incisor proclined and one retroclined. The dible can be due to an increase in the cranial base angle. However,
cephalometric definition of Class II is when the ANB angle is an increase in the cranial base length leads to a prognathic maxilla.
greater than 4° for the Caucasian population. If a Class II malocclusion exists on a skeletal Class I base, the incisor
relationship may be due to the soft tissue or environmental factors,
for example, digit sucking or a lower lip trap.
Incidence of Class II Division 1 malocclusion 2. Dental Features such as:
The incidence of Class II Division 1 is 20% (Todd and Lader, 1991),
• Increased overjet.
representing the most prevalent malocclusion in Caucasian popu-
lations (Foster and Walpole Day, 1974, Helm, 1968, Proffit et al., • Spacing of the upper incisors.
1998). The prevalence of Class II intermediate is 10% (Williams
and Stephens, 1992), while Class II indefinite is found in 9 % of the • Lower incisors are crowded or proclined depending
population. (which population) upon the lower lip trap.
Aetiology of Class II Division 1 malocclusion • Deep bite, or an open bite.
These include: • An open bite may exist due to an adaptive swallow-
1. Skeletal factors such as: ing pattern, secondary to increased overjet,
• Class I or mild Class II skeletal base relationship. BATISTA, K. B., THIRUVENKATACHARI, B., HARRISON, J. E. &
D O’BRIEN, K. 2018. Orthodontic treatment for prominent upper
• Average or reduced lower face height. front teeth (Class II malocclusion) in children and adolescents.
Cochrane Database of Systematic Reviews.
• Very mild transverse discrepancies.
BSI 1983. British standard glossary of dental terms, British Stan-
Dental features (Burden et al., 1999): dards Institution.
• Favourable if overjet is less than 9mm and com- BURDEN, D. J., MCGUINNESS, N., STEVENSON, M. & MC-
bined with proclined incisors. NAMARA, T. 1999. Predictors of outcome among patients with
Class II Division 1 malocclusion treated with fixed appliances in
• Average or slight increased overbite.
the permanent dentition. American journal of orthodontics and
• Mild to moderate crowding. dentofacial orthopedics, 116, 452-459.
• Molar relationship is less than 3/4 unit Class II. CHHIBBER, A., UPADHYAY, M., URIBE, F. & NANDA, R. 2010.
Long-term stability of Class II correction with the Twin Force Bite
Indicators for orthognathic surgery Corrector. Journal of clinical orthodontics: JCO, 44, 363-376.
• Adult/non-growing patients. FOSTER, T. & WALPOLE DAY, A. 1974. A survey of malocclu-
sion and the need for orthodontic treatment in a Shropshire school
• Severe skeletal discrepancy. population. British Journal of Orthodontics, 1, 73-78.
• Overjet 10mm or more. HELM, S. 1968. Malocclusion in Danish children with adolescent
• Pog to Nasion perpendicular is 18mm or more. dentition: an epidemiologic study. American journal of orthodon-
tics, 54, 352-366.
• Mandibular corpus length is less than 70 mm.
HOPKINS, G., HOUSTON, W. & JAMES, G. 1968. The cranial base
• Facial height more than 125mm. as an aetiological factor in malocclusion. Angle Orthod, 38, 250-5.
• Transverse discrepancies greater than 3mm were JANSON, G., ARAKI, J. & CAMARDELLA, L. T. 2012. Posttreat-
not considered orthodontically treatable. ment stability in Class II nonextraction and maxillary premolar
extraction protocols. ORTHODONTICS: The Art & Practice of
• ANB is greater than 9°. Dentofacial Enhancement, 13.
• Severe vertical or transverse discrepancy. JANSON, G., LEON-SALAZAR, V., LEON-SALAZAR, R., JAN-
SON, M. & DE FREITAS, M. R. 2009. Long-term stability of Class
• Severe deep bite with decreased incisor show on a II malocclusion treated with 2-and 4-premolar extraction proto-
smile. cols. American Journal of Orthodontics and Dentofacial Orthope-
Aetiologies of relapse of treated Class II Division 1 malocclu- dics, 136, 154. e1-154. e10.
sion KING, G. J., KEELING, S. D., HOCEVAR, R. A. & WHEELER,
T. T. 1990. The timing of treatment for Class II malocclusions in
• Biological factors: Lack of gingival and periodontal children: a literature review. Angle Orthod, 60, 87-97.
remodelling,
KOROLUK, L. D., TULLOCH, J. F. & PHILLIPS, C. 2003. Incisor
• Iatrogenic factors: Movement of teeth out of equilib- trauma and early treatment for Class II Division 1 malocclusion.
rium of soft tissue Am J Orthod Dentofacial Orthop, 123, 117-25; discussion 125-6.
• Growth factors: Differential growth factor which MIHALIK, C. A., PROFFIT, W. R. & PHILLIPS, C. 2003. Long-
predisposes to relapse. term follow-up of Class II adults treated with orthodontic
camouflage: a comparison with orthognathic surgery outcomes.
• Environmental factors: continued parafunctional American Journal of Orthodontics and Dentofacial Orthopedics,
habits, 123, 266-278.
• Idiopathic causes: Idiopathic condylar resorption O’BRIEN, K., WRIGHT, J., CONBOY, F., CHADWICK, S.,
(ICR), OR CONNOLLY, I., COOK, P., BIRNIE, D., HAMMOND, M.,
HARRADINE, N., LEWIS, D., MCDADE, C., MITCHELL, L.,
• Any combination of the above. MURRAY, A., O’NEILL, J., READ, M., ROBINSON, S., ROBERTS-
HARRY, D., SANDLER, J., SHAW, I. & BERK, N. W. 2003a.
Effectiveness of early orthodontic treatment with the Twin-block
appliance: a multicenter, randomized, controlled trial. Part 2: Psy-
chosocial effects. Am J Orthod Dentofacial Orthop, 124, 488-94;
discussion 494-5.
O’BRIEN, K., WRIGHT, J., CONBOY, F., SANJIE, Y., MANDALL,
13
Written by: Mohammed Almuzian, Haris Khan, Awrisha Tariq
In this Chapter
1. Classification of Class II Division 2 malocclusion
2. Incidence of Class II Division 2 malocclusion
3. Aetiology of Class II Division 2 malocclusion
4. Features of Class II Division 2 incisor relation
ships
5. Justification for treatment
6. Treatment aims
7. Treatment considerations
8. Treatment option
9. Timing of treatment
10. Stability and retention
11. Proclination of lower incisors in Class II Divi
sion 2 cases
12. EXAM NIGHT REVIEW
C lass II Incisor relationship: The lower incisor edge oc-
nines among Class II Division 2 subjects (Basdra et
al., 2000).
cludes palatal to the cingulum plateau of the upper central
incisor, with retroclined upper incisors and the overjet usu- 2. Environmental factors such as:
ally being minimal or possibly increased (BSI, 1983). If the • Soft tissue factors: A high resting position of the
overjet is in the range of 5-7 mm and incisors are retroclined, lower lip over the upper incisors results in increased
it is known as Class II intermediate (Williams, 1992) resting pressure, approximately 2.5 times greater
Classification of Class II Division 2 malocclusion than upper lip resting pressure, which is linked with
retroclination of the maxillary incisors (Lapatki et
Van der Linden’s sub-classification of Class II Division 2 is al., 2002). Hyperactive or hypertonic lips or a ‘strap-
based on the position of the upper incisors and canines rela- like lower lip’ have been implicated in the Class II
tive to each other (Van der Linden, 1983). Division 2 (Karlsen, 1994).
• Type A: The upper central and lateral incisors are • Dental factors such as overeruption of the incisors,
retroclined, with no overlapping by canines. It is less long central and short lateral incisors, which results
severe in nature. in the lateral incisors ‘escaping’ from the effects of
• Type B: The central incisors are retroclined and the lower lip force, increased crown root angle of the
overlapped by the lateral incisors. upper incisor, known as the Collum angle (McIntyre
and Millett, 2003), and thin incisors with small cin-
• Type C: The central and lateral incisors are retro- gulum.
clined and overlapped by the canines.
• Skeletal factors due to increased cranial base length
• Type D: A combination of the above subtypes. and angle (Hopkins et al., 1968) or reduced lower
Incidence of Class II Division 2 malocclusion facial height (Pancherz et al., 1997).
Class II Division 2 is a relatively uncommon malocclusion, • Growth factors due to overdevelopment of the up-
representing 2.3-5% of all malocclusions of the Western Cau- per anterior alveolar process or forward rotation of
casian population (Ast et al., 1965)(Mills, 1966). The preva- the mandible result in the lower lip moving superi-
lence in children in the United Kingdom is 10% (Millett et al., orly in position.
2012, Foster and Day, 1974). Features of Class II Division 2 incisor relationships
Aetiology of Class II Division 2 malocclusion 1. Skeletal features such as
Class II Division 2 is a combination of environmental and • Usually mild Class II skeletal base but can be I or III.
genetic factors.
• Increased cranial base angle leading to mandibular
1. Genetic and familial origin: The evidence that Class II retrognathia (Hopkin et al., 1968).
Division 2 could have a genetic component are:
• Longer cranial base leading to the prognathic max-
• The study of 20 monozygotic twins showed that illa.
all twins had a Class II Division 2 incisor relation-
ship, while only 10.7% of 28 dizygotic twins had a • Decreased lower face height, gonial angle, mandib-
Class II Division 2 incisor relationship (Markovic, ular plane angle and skeletal deep bite (Al-Khateeb
1992). The high concordance in monozygotic twins and Al-Khateeb, 2009).
and much lower concordance for dizygotic twins • Maxilla may be short, broad and forward relative to
suggests that Class II Division 2 have an autosomal the mandible leading to a tendency for a scissor bite.
dominant inheritance pattern, with more than one
genetic factor contributing to this malocclusion. 2. Soft tissue features such as
• Tooth agenesis, excluding third molars, was at least • High resting lower lip line due to decreased lower
three times more common in Class II Division 2 face height.
subjects than in the general population (Basdra et • Typically strap-like lower lip (increase in muscular
al., 2000). tone).
• Reduced width of lateral incisors had a greater prev- • Marked labio-mental fold, and
alence in Class II Division 2 incisor relationships
• High masseteric muscle forces due to hypertrophic
(Peck et al., 1998).
muscle (Ingervall and Thilander, 1974,Sciote et al.,
• An increased prevalence of impacted maxillary ca- 2012).
• Edge to centroid relation, IIA and move upper inci- BASDRA, E. K., KIOKPASOGLOU, M. & STELLZIG, A. 2000. The
Class II Division 2 craniofacial type is associated with numerous
sors away from lower lip.
congenital tooth anomalies. Eur J Orthod, 22, 529-35.
Retain long-term BJORK, A. & SKIELLER, V. 1972. Facial development and tooth
• URA with flat anterior bite plane (FABP) with or eruption. An implant study at the age of puberty. Am J Orthod, 62,
without bonded retainer upper labial segment. 339-83.
BREZNIAK, N., ARAD, A., HELLER, M., DINBAR, A., DINTE, A.
• CSF of rotated upper laterals (Edwards, 1970).
& WASSERSTEIN, A. 2002. Pathognomonic Cephalometric Char-
acteristics of Angle Class II Division 2 Malocclusion. The Angle
Orthodontist, 72, 251-257.
BSI 1983. British standard glossary of dental terms, British Stan-
dards Institution.
CANUT, J. A. & ARIAS, S. 1999. A long-term evaluation of treated
Class II division 2 malocclusions: a retrospective study model
analysis. Eur J Orthod, 21, 377-86.
DYER, F. M., MCKEOWN, H. F. & SANDLER, P. J. 2001. The
modified twin block appliance in the treatment of Class II division
2 malocclusions. J Orthod, 28, 271-80.
EDWARDS, J. G. 1970. A surgical procedure to eliminate rotational
relapse. Am J Orthod, 57, 35-46.
FERES, M. F. N., ROZOLEN, B. S., ALHADLAQ, A., ALKHADRA,
T. A. & EL-BIALY, T. 2018. Comparative tomographic study of the
maxillary central incisor collum angle between Class I, Class II,
division 1 and 2 patients. Journal of orthodontic science, 7.
FOSTER, T. D. & DAY, A. J. 1974. A survey of malocclusion and
the need for orthodontic treatment in a Shropshire school popula-
tion. Br J Orthod, 1, 73-8.
HOPKIN, G. B., HOUSTON, W. J. & JAMES, G. A. 1968. The cra-
nial base as an aetiological factor in malocclusion. Angle Orthod,
38, 250-5.
HOPKINS, G., HOUSTON, W. & JAMES, G. 1968. The cranial base
as an aetiological factor in malocclusion. Angle Orthod, 38, 250-5.
HOUSTON, W. J. 1989. Incisor edge-centroid relationships and
overbite depth. Eur J Orthod, 11, 139-43.
INGERVALL, B. & THILANDER, B. 1974. Relation between facial
morphology and activity of the masticatory muscles. J Oral Reha-
bil, 1, 131-47.
KARLSEN, A. T. 1994. Craniofacial characteristics in children with
Angle Class II div. 2 malocclusion combined with extreme deep
bite. The Angle Orthodontist, 64, 123-130.
LAPATKI, B. G., MAGER, A. S., SCHULTE-MOENTING, J. &
JONAS, I. E. 2002. The importance of the level of the lip line and
Written by: Mohammed Almuzian, Haris Khan, Abbas Naseem, Taimoor Khan
14
In this Chapter
1. Classification of Class III malocclusion
2. Prevalence of Class III malocclusion
3. Aetiology of Class III malocclusion
4. Clinical features of Class III malocclusion
5. Treatment options for Class III malocclusion
6. Interceptive treatment
7. Growth Modification
8. Orthodontic camouflage treatment
9. Favourable features for orthodontic camouflage
10. Guidelines for orthodontic camouflage
11. Consideration of a single lower incisor extrac
tion
12. Bracket prescription can aid camouflage of the
Class III malocclusion
13. Dental decompensation and orthognathic sur-
gery
14. Surgical options
15. EXAM NIGHT REVIEW
C lass III incisors relationship means that the incisal edge of
Aetiologies of Class III malocclusion
Two significant factors have been identified in the aetiology
the mandibular incisors lies ahead of the cingulum plateau of
the maxillary incisors, according to the British Standard In- of the Class III malocclusion (Singh, 1999):
stitute (BSI) classification (BSI, 1983). While Class III molars 1. Positional cause: Due to the change in skeletal position,
relationship means that the mesiobuccal cusp of the perma- shown in cephalometric angular measurements due to altera-
nent maxillary first molar lies distal to the buccal groove of tion in growth pattern.
the permanent first mandibular molar (Cobourne and DiBi-
2. Quantitative cause: It is reflected as linear measurements
ase, 2015). Class III canine relationship means that the upper
due to a size alteration due to craniofacial overgrowth beyond
canine cusp tip lies posterior to the embrasure space between
normal limits.
the lower canine and the first premolar. The cephalometric
definition of Class III malocclusion is when the ANB angle Aetiological factors can be summarised into:
for the Caucasian population is less than 2° (Cobourne and
1. Genetic factors: Class III malocclusion is believed to be
DiBiase, 2015).
inherited genetically due to its familial tendency (Hapsburg
Classification of Class III malocclusion jaw). Mandibular prognathism can also be caused by certain
X-chromosome aneuploid conditions (abnormal number of
These include:
chromosomes in a haploid set).
• True Class III malocclusion refers to the Class III
2. Environmental factors such as (Gottlieb and Gottlieb,
buccal occlusion bilaterally, with anterior crossbite
1954):
or edge to edge incisor relationship (Cobourne and
DiBiase, 2015). • Enlarged tonsils (Proffit et al., 2006).
• Pseudo-Class III malocclusion refers to the Class 1 • Premature loss of the first molars.
skeletal relationship with bilateral buccal Class I oc-
• Macroglossia.
clusion and anterior crossbite or edge to edge incisor
relationship due to functional anterior mandibular • Cleft lip and palate and scarring secondary to cleft
displacement (Rabie and Gu, 2000). repair.
• Class III subdivision (asymmetry) refers to Class III • Disease of the pituitary gland and associated hor-
buccal occlusion on one side (subdivision) and Class monal disturbances, for example, acromegaly.
I on the other (Janson et al., 2010).
• Trauma and irregular eruption of permanent inci-
Classification Class III malocclusion based on the severity sors or loss of deciduous incisors (Gorlin et al., 1965,
Angle, 1907).
Overjet based classification (Proffit et al., 2006) include:
• Other contributing factors are the relative position
• Mild Class III- 0 mm
and size of the cranial base, maxilla, mandible and
• Moderate Class III -1 to -2mm temporomandibular articulation (Gold, 1949, Jena
et al., 2005, Hopkin et al., 1968, Battagel, 1993).
• Severe Class III -3 to -4 mm
Clinical features of Class III malocclusion
• Extreme >-4 mm
These include:
Cephalometry based classification is based on the magnitude
of the ANB angle ( Kerr et al., 1992) and includes:: 1. Skeletal features such as:
• Mild Class III >-2° • Short anterior cranial base.
• Moderate Class III -2°to -4° • Short posterior cranial base.
• Severe Class III <-4° • Maxillary retrusion (25%).
Prevalence of Class III malocclusion • Mandibular prognathism (18.7%).
Low prevalence in the western population, ranging from •
Combination of both retrognathic maxilla and
3-5% (Todd and Lader, 1991, Cobourne et al., 2012). How- prognathic mandible (22.2%).
ever, higher a prevalence has been reported in the Asian
• Anterior position of TMJ (Chen et al., 2008).
population of 13% (Xue et al., 2011). The incidence of an-
terior crossbite in the Caucasian population is around 10% • Increased mandibular length.
(O’Brien, 1994).
• Obtuse gonial angle.
• Western population 3-5% (Todd and Lader, 1991, Favourable features for Orthodontic camouflage (Co-
Cobourne et al., 2012). bourne and DiBiase, 2015)
• 13% Asian population (Xue et al., 2011). Anterior • The patient completed a growth spurt.
crossbite Caucasians 10% (O’Brien, 1994). • Near to normal soft tissue profile.
Aetiology of Class III malocclusion • Normal or mild transverse relations.
1. Genetic factors • No obvious facial asymmetry.
2. Environmental factors • Mild skeletal discrepancy.
• Enlarged tonsils (Proffit et al., 2006). • Adequate vertical relationship and average overbite.
• Premature loss of the first molars, • In the absence of displacement, the patient can
• Macroglossia, achieve edge to edge bite in RCP.
• Cleft lip and palate and scarring secondary to cleft • Minimal dento-alveolar compensation.
repair, • Mild lower arch crowding to optimise the uses of ex-
• Disease of the pituitary gland and the associated traction spaces to correct the overjet.
hormonal disturbances Guidelines for Orthodontic camouflage
• Trauma and irregular eruption of permanent inci- • UI 120° to PP
sors or loss of deciduous incisors (Gorlin et al., 1965,
Angle, 1907), • LLS 80° to MP
• Other factors (Gold, 1949, Jena et al., 2005, Hopkin • lower single incisor extraction to retrocline LLS.
et al., 1968, Battagel, 1993) • For retroclination of LI, closing space on an under-
Classification of the severity of Class III Malocclusion sized rectangular or round stainless steel wire.
mild >-2 , moderate -2°to -4°,severe: <-4° • Class 3 elastics to procline UI & retrocline LI.
15
Written by: Mohammed Almuzian, Haris Khan, Maham Munir, Abbas Naseemn
In this Chapter
1. Types of maxillary skeletal deficiency 20. Interpretation mid-palatal suture maturation
2. Benefits of treating displacement classification:
3. Incidence of transverse maxillary deficiency 21. Mid-palatal suture density ratio
4. Age-related changes in maxillary dimension 22. Protocols of maxillary expansion
5. Aetiology of transverse maxillary deficiency 23. Modern designs of RME/ Mini-implant assisted
rapid palatal expansion (MARPE)
6. Clinical features of transverse maxillary defi
ciency 24. Surgical maxillary expansion
7. Diagnosis of transverse maxillary deficiency 25. Indications for SARPE
8. Treatment objectives 26. Complications during SARPE
9. How much expansion is required? 27. Retention and stability secondary to MPMO
10. Non-surgical maxillary expansion 28. Factors & Yardsticks
11. Principle of RME 29. Appliances for unilateral maxillary expansion
12. The rationale for expansion treatment 30. Treatment of scissor bite
13. Types of conventional RME 31. Stability and retention of expansion
14. The influence of the height of RME 32. Anterior crossbites
15. Proposed Indications for RME 33. Requirement for the successful result using URA
16. Contraindications and limitations of conven 34. EXAM NIGHT REVIEW
tional RME
17. Potential complications of RME
18. Mid-palatal suture assessment methods
19. Mid-palatal suture maturation classifica-
tion
T ransverse maxillary deficiency is defined as a constricted
first mandibular molars or the distance between the
most cervical extension of the buccal grooves on the
maxilla relative to the mandible (Proffit et al., 2006). It can mandibular first molars (Garino and Garino, 2002).
manifest with the following:
• Palatal width: Minimum distance at the gingival lev-
• Anterior crossbite: The upper anterior teeth are palatally el between maxillary first molars (Lux et al., 2003) or
positioned in their relationship to the lower anterior the distance between the mesio-lingual cusp tips of
teeth (Prakash and Durgesh, 2010). the first molars (Isaacson et al., 1971).
• Posterior crossbite: In centric relation, the upper poste- • Trans-palatal width: The distance between the right
rior teeth are palatal relative to the opposing lower pos- and left gingival ends of the palatal grooves of the
terior teeth. This is the most common type of crossbite maxillary first molars.
(Andrade et al., 2009).
• Telescopic bite: Bilateral mandibular lingual cross-
When there is a discrepancy, the mandible encounters a de- bite. The mandibular posterior teeth are lingual to
flecting contact, which is displaced. Displacements can be the maxillary teeth.
anterior, posterior or lateral.
• Brodie bite: Unilateral or bilateral complete poste-
Different terminologies in transverse maxillary deficiency rior buccal crossbite, also called Brodie syndrome.
These include: It is a severe transverse discrepancy when all buccal
cusps of the lower molars are telescoped within the
• Crossbite: A discrepancy of the tooth relationship in lingual cusps of the upper molars (Valencia, 2007).
the transverse plane of space (BSI, 1983). Incidence is around 1.0% to 1.5%.
• Buccal crossbite: The buccal cusps of the mandibu- Types of maxillary skeletal deficiency
lar teeth occlude laterally or buccally to the buccal
cusps of the maxillary teeth (BSI, 1983). There are two types of maxillary skeletal deficiency (Haas,
1965, Kutin and Hawes, 1969):
• Lingual crossbite: The buccal cusps of the mandibu-
lar teeth occlude lingually to the palatal cusps of the • Relative maxillary deficiency: when the maxilla is
maxillary teeth. of normal size compared to the upper face and the
cranium, the mandible is comparatively large.
• Unilateral crossbite: Crossbite affects one side of the
dental arch, which may or may not be associated • Real maxillary deficiency: The maxilla size is small
with functional mandibular displacement (Palla and compared to the mandible and midface. Upper
N, 2018). posterior teeth can either be on the basal bone or
inclined buccally to occlude the mandibular teeth
• Bilateral crossbite: Both sides of the dental arch are (transverse compensation).
affected and are in crossbite.
• Haas introduced the terms relative and absolute
• Crossbite tendency: The tooth-to-tooth contact in transverse discrepancy (Haas, 1961):
the transverse plane are in edge to edge relationsip
in the occlusion (Grammatopoulos et al., 2012). • Relative transverse discrepancy: This is due to an-
tero-posterior positioning of the mandible.
•
Displacement: The functional deflection of the
mandible on closing from retruded contact position • Absolute transverse discrepancy exists when the
(RCP) to the intercuspal position (ICP). There is a posterior teeth do not coordinate in centric relation
discrepancy between the muscular positioning of or on dental models when canines are placed into a
the mandible (centric position) and that dictated by Class I relationship.
the teeth coming into the occlusion (centric occlu- Benefits of treating displacement
sion) (Cobourne et al., 2012).
These include:
• Upper inter-molar width: The distance between the
mesiobuccal cusps tips of the right and left maxillary • Aesthetic benefits by widening the buccal corridor
first molars (Garino and Garino, 2002), or the dis- • Eliminate the undesirable growth, which can result
tance between the central fossae of the permanent in mandibular displacment and eventually to true
maxillary molars on the right and left sides (Lux et mandibular asymmetry
al., 2003).
• Potentially avoid TMD in the susceptible patient
• Lower inter-molar width: The distance between the (weak evidence)
cusp tips of the distobuccal cusps of the right and left
Other studies showed that: 1. Recording functional jaw displacement: Record any func-
tional jaw displacement from RCP to ICP in direction and
• Transpalatal width increased only 2.6 mm from age quantity. Absence of displacement indicates that the crossbite
7 to 15. After 12 years of age, there is no change for is of a skeletal origin (Piero, 2006).
females and very little increase (about 1mm) for
males in both maxilla and mandible (McNamara et 2. Study model measurements: Measure the palatal width
al., 2001) (X) and the lower inter-molar width (Y) on the study model
(Proffit et al., 2006). Distances between the midpoint of teeth
• The inter-canine widths of upper and lower arches could be measured in mm and compared to a tabulated tem-
tend to decrease slightly during the permanent den- plate (Moyers, 1976).
tition (around 12 years old) for both males and fe-
males (Bishara et al., 1997). 3. Radiography: A Posterior-Anterior (PA) cephalogram or
CBCT can be used to calculate transverse skeletal discrep-
Aetiologies of transverse maxillary deficiency ancies between the maxilla and the mandible (Allen et al.,
The causes of maxillary constriction may include dental, soft 2003). The following measurements can be recorded:
tissue and skeletal components and are listed below (Allen et • Effective maxillary width (JL-JR): The distance be-
al., 2003, Andrade et al., 2009): tween JL and JR (bilateral points located at a depth
• Hereditary of concavity of the lateral maxillary contour, at the
junction of the maxilla and zygomatic buttress).
• An alternative is to use a mandibular lingual arch to • For dentoalveolar or mild skeletal changes, a chin-
stabilise the lower teeth and attach cross elastics to cap or Frankel 3 (Functional) can be used
the maxillary teeth at fault. • Bodily movement using fixed 2x4 appliance
• TAD’s can hold the unaffected side and allow the • Simple tipping movement using URA with posterior
conventional expansion technique to work on the capping, Z spring, double cantilever spring, crossed
affected side. cantilever spring, screw plate.
Treatment of scissor bite An RCT by Wiedel and Bondemark 2014 showed that either
These include: fixed or removable appliance therapy could successfully cor-
rect anterior crossbite with the functional shift in the mixed
• Mild to moderate cases: In a child, a functional ap- dentition from a short-term perspective (Wiedel and Bond-
pliance can be used to correct this relationship by emark, 2015a). Wiedel and Bondemark followed their cases
advancing the mandible forward. This may help cor- and found no difference in terms of stability between fixed
rect the lingual crossbite. In adults, fixed appliances and removable appliances (Wiedel and Bondemark, 2015b).
can be used with cross-elastics and an expanded The same research team undertook another study using the
mandibular archwire, buccal crown torquing of the same sample and found that the cost-effectiveness of a URA
lower posterior teeth or an expanded archwire. is poorer than a fixed appliance (Wiedel et al., 2016). An-
• Severe cases: If there is a skeletal Class II base re- other paper by the same group using the same sample found
lationship, mandibular advancement surgery may that both appliances were low to moderate in terms of pain
help correct the lingual crossbite. Surgical tech- and discomfort (Wiedel and Bondemark, 2016).
niques using distraction osteogenesis for widening Requirement for the successful results using URA
the mandibular arch or constriction of the maxillary
These include:
• Premature contact leading to mandibular functional • Positioned over the main appliance
shift Rapid Maxillary Expansion RME
• Arch length discrepancy and crowding • Banded; tooth-borne (HYRAX/ Biedermann and
• Habits such as thumb sucking Isaacson appliances) or tooth and tissue borne (Haas
and Derichsweiler appliances)
• Obstruction of the upper airway due to the enlarged
adenoids • Bonded appliance i.e. mostly tooth-tissue borne.
16
Asymmetries
Written by: Mohammed Almuzian, Haris Khan, Eesha Najam
In this Chapter
1. Prevalence of dental & skeletal asymmetries 15. Hemifacial atrophy (Parry-Romberg syn
2. Aetiology of dental & skeletal asymmetries drome)
3. Classification of dental & skeletal asymme 16. Asymmetric mandibular excess
tries 17. Management of asymmetric mandibular
4. Traumatic asymmetry excess
5. Management of condylar fractures in chil 18. Mandibular displacements on closure
dren 19. Dental asymmetries
6. Hemifacial microsomia (HFM) 20. Causes of dental midline asymmetry
7. Clinical features of HFM 21. Class II subdivision
8. Types of HFM 22. Class III subdivisions
9. Classification of HFM 23. Examination of asymmetry
10. Juvenile Rheumatoid Arthritis (JRA) 24. Management of functional asymmetry
11. Treatment of Juvenile Rheumatoid Arthritis 25. Management of skeletal asymmetry
12. Idiopathic condylar resorption (ICR) 26. EXAM NIGHT REVIEW
13. Torticollis (Wry Neck)
14. Hemifacial hypertrophy
A symmetry is defined as an absence of conformity in size,
sure and moulding, habits e.g. thumb sucking and
condylar hypoplasia/ hyperplasia
shape and relative position of parts on either side of a divid-
ing line or median plane or about a centre or an axis. Facial • Developmental factors (Chia et al., 2008) such as
asymmetry is defined as an imbalance between the left and Hemimandibular elongation/ hyperplasia, Condy-
right sides of the face (Chia et al., 2008). At the same time, lar hypo- or hyperplasia, Hemifacial macrosomia,
dental asymmetry represents dental midline discrepancy Hemifacial hypertrophy, Hemifacial atrophy (Parry-
from the facial midline. Romberg syndrome), Achondroplasia, Torticollis,
Unilateral cleft lip and palate and Childhood frac-
Prevalence of dental & skeletal asymmetries tures of the jaw.
Amongst orthodontic patients, 12% had facial asymme- • Pathological factors such as Tumors of the head and
tries and 21% dental asymmetries. The most common neck region ( Ameloblastoma arising in body and ra-
asymmetry was mandibular midline deviation (62%), mus of mandible, tumours of condylar head includ-
followed by non-coincident dental midlines (46%), max- ing osteoma, osteochondroma, chondrosarcoma),
illary midline deviation from the facial midline (39%), cysts (Dentigerous cysts, keratocysts, lymphoepi-
molar classification asymmetry (22%), maxillary occlu- thelial cysts), Fibrous dysplasia, Infection (Dento-
sal asymmetry (20%), mandibular occlusal asymmetry alveolar abscesses, acute parotitis), Decreased tonic
(18%), facial asymmetry (6%), chin deviation (4%), and muscular activity (muscle weakness syndromes such
nose deviation (3%) (Sheats, 1998). as cerebral palsy, muscular dystrophy), Muscular
Most people have an asymmetry in the face and dentition, atrophy due to impaired motor nerves and condy-
but it is usually sub-clinical (Shah and Joshi, 1978) with lar resorption due to juvenile rheumatoid arthritis,
no gender difference was noted (Melnik, 1991); however, post-steroid therapy and following orthognathic
the right side of the face is commonly larger than the left surgery.
side (Peck et al., 1991). The clinical threshold for skeletal • Traumatic factors including condylar fractures and
asymmetry was close to 5mm (McAvinchey et al., 2014). subsequent ankylosis, which results in an asymme-
Regarding dental asymmetry, 56% of laypersons and 83% try of the jaw (Proffit et al., 1980).
of orthodontists can recognize a 2mm dental asymme-
try (Burden 1999). A systematic review found up to 2.2 • Functional factors include the functional shift from
mm of midline deviation is considered acceptable (Jan- centric occlusion to centric relation (CO-CR), lead-
son 2011). A cant of 10º or greater was considered unac- ing to mandibular displacement and asymmetry in
ceptable by 70% of orthodontists and 40% of laypeople growth. This is primarily due to constricted maxilla
(Thomas 2008). or premature contacts.
Growing children between the age of 7 to 16 may mani- • Idiopathic and iatrogenic factors such as idiopathic
fest mandibular asymmetry, and history of trauma was condylar resorption and improper orthodontic or
found in only 14% of patients with asymmetry. The dis- orthognathic planning and treatment
crepancy can appear to reduce for some patients due to • Local factors such as retained/ missing teeth or pre-
bony remodelling and soft tissue camouflage (Melnik, mature loss of primary teeth
1992, Liukkonen et al., 2005). 26% of orthognathic pa-
Classification of dental & skeletal asymmetries
tients present with facial asymmetry (Proffit, 1996),
mainly class III (40%) followed by Class II orthognathic These include:
cases (25%). The mandible and the dentoalveolar region
• Skeletal asymmetry mainly affects maxillary, man-
exhibited the greatest degree of asymmetry. This is be-
dibular basal bone or their combination (Bishara et
cause the growth of the mandible exhibits the longest pe-
al., 1994).
riod of growth and 90% of mandibular deviations are to
the left. Chin deviation affects 80% of orthognathic cases, • Dental asymmetry due to retained or missing teeth
and overall, 60% had an asymmetry in the lower face. The or habits e.g. Thumb-sucking
midface (primarily the nose) also was affected in about
• Muscular asymmetry, including any craniofacial
30% of the asymmetric patients.
muscle hypertrophy or atrophy such as cerebral pal-
sy.
Aetiology of dental & skeletal asymmetries • Functional asymmetry secondary to TMJ dysfunc-
tion or a CO-CR shift.
These include:
Overview of different types of asymmetry
• Environmental factors such as intra-uterine pres-
158 Asymmetries
Traumatic asymmetry • Severely malformed or absent pinna of the ear.
Condylar fractures are mostly unilateral, with 75% of chil- • Periauricular skin tags.
dren having normal mandibular growth without the devel-
• Variable degrees of nerve palsy (due to the associa-
opment of an asymmetry. Moreover, most condylar fractures
tion of specific cranial nerves with branchial arches)
remain undiagnosed (Proffit et al., 1980).
• Reduction in size or flattening of facial bones due to
Management of condylar fractures in children
the reduced size of the masticatory muscles.
These include:
• Mandibular asymmetry of varying severity (unilat-
• Immobilization followed by early mobilization. eral aplasia or hypoplasia of the mandibular ramus
and condyle).
• Hybrid functional appliance: The aim of growth
modification in asymmetry cases is to achieve more • Cleft lip and palate, palatal and tongue muscle hy-
growth on one side than the other (Turvey et al., poplasia and velopharyngeal insufficiency occur less
2004). Hybrid functional appliances consist of sev- commonly.
eral components to achieve selective dento-alveolar
• Unilateral crossbite on the affected side and canting
eruption, mandibular repositioning and optimal
of the occlusal plane.
linguofacial muscle balance, which favour growth to
compensate for asymmetric mandibular deficiencies • Disturbed tooth development on the affected side
(Vig et al., 1986). A wax bite is taken to achieve a (hypodontia is 5 times more common compared
symmetric jaw relationship in three planes of space. with the average population) (Monahan et al., 2001).
A greater vertical opening is registered on the af-
Types of HFM
fected side; with this, downward torque of the ramus
improve the vertical defect. The unaffected side fea- These include:
tures a posterior bite plane to inhibit tooth eruption • Type I Hypoplastic temporomandibular joint
and allow the deficient side to allow teeth eruption.
A lingual shield is incorporated on the affected side • Type II—hypoplastic and abnormal shape of the
to prevent the tongue from interfering with tooth mandibular ramus, condyle, and temporomandibu-
eruption. A buccal shield is incorporated on the af- lar joint
fected side to achieve transverse expansion. • Type III Absence of the mandibular ramus
• Suppose the translation of the condyle is severely re- • Type IV Mandibular body hypoplasia
stricted due to post-traumatic scarring. In that case,
pre-functional surgical intervention is indicated to Classification of HFM
remove restrictions on growth and allow translation Kaban’s modified classification (Madrid et al., 2010) clas-
of the condyle, followed by hybrid functional appli- sified HFM according to the extent of malformation and
ance therapy and regular jaw exercises. managemet (Table 1).
Hemifacial microsomia (HFM) Juvenile Rheumatoid Arthritis (JRA)
This is a congenital disorder associated with unilateral devel- It is an inflammatory disease process that affects bone and
opmental defects in the orofacial region. The proposed aeti- cartilage. In JRA with one to three affected joints, the TMJ is
ologies for HFM include: involved in 33% of cases, while in JRA with greater than four
• Defect in proliferation and migration of neural crest affected joints, the TMJ is involved in 80% of cases (Ince et al.,
cells resulting in defects of 1st and 2nd arch struc- 2000). Progressive destruction of condyles results in shorten-
tures. ing of the ramus and downward and backward rotation of the
chin, which leads to chin deficiency and anterior open bite.
• Hemorrhage of the stapedial artery (Poswillo, 1973). Condylar resorption may occur faster on one side than the
• Goosecoid (Gsc) - potential candidate gene for other, resulting in mandibular asymmetry in 2/3rds – 3/4ths
Hemifacial microsomia (Kelberman et al., 2001). of affected children.
Clinical features of HFM
These include:
• Narrowed palpebral fissures.
• Unilateral epibulbar dermoids.
Asymmetries 159
Features Treatment approach
Grade 1 Soft tissues and mandible present, Functional appliance therapy is attempted before sur-
gery.
hypoplastic temporomandibular joint
Grade 2a Hypoplastic and abnormal shape of the man- Same approach as for grade 1
dibular ramus, condyle, and temporomandibular
Early surgical intervention to lengthen the ramus
joint, and effects on muscles of mastication
through distraction + / - functional appliance therapy.
Orthognathic surgery as an adult.
Grade 2b Mandibular ramus is hypoplastic and markedly Condyle is considered to be non-functional. Early sur-
abnormal in form and location, being medial gery involving costochondral graft.
and anterior.
Total joint replacement as an adult.
Grade 3 Complete absence of the condyle and ramus as Same approach as for the severe grade 2
well as severe soft tissue defects
Table 1: Kaban’s modified classification of HFM
Hemifacial hypertrophy
Treatment of Juvenile Rheumatoid Arthritis
It is hypertrophy of one side of the face, and it is mainly due
These include: to the asymmetric distribution of neural crest cells. It is char-
• Methotrexate is the most effective agent for retard- acterized by overgrowth in the craniofacial structures (in-
ing disease progression. cluding soft and hard tissues). Occlusion is also likely to be
affected.
• Functional appliances and any surgical procedures
which affect the TMJ (e.g. orthognathic surgery or
distraction osteogenesis) should be avoided. The Hemifacial atrophy (Parry-Romberg syndrome)
application of force on the TMJ accelerates disease
processes and condylar destruction. It is progressive atrophy of soft tissues and underlying bones
on one side of the face. More common on the left side and
• Total TMJ replacement in severe cases. in females. Clinical features of Parry-Romberg syndrome are:
• Surgical maxillary impaction might be considered • Atrophic facial changes include tissues around the
in adolescents as this results in upward and forward nose and nasolabial folds, which later progress to the
rotation of the mandible, improving open bite and angle of the mouth, eyes, ears and neck (follows the
chin deficiency. Relapse is expected as a shortening distribution of the trigeminal nerve).
of ramus continues (disease progression at the TMJ).
• Hyperpigmentation of the skin.
• Augmentation genioplasty improves facial appear-
ance and does not add extra load on the TMJ. • Seizures
The predisposing factors for ICR are preoperative temporo- • Muscle and facial bone atrophy lead to mandibular
mandibular joint dysfunction (Hwang et al., 2004), young asymmetry.
and female patients (due to hormonal factors) and high man- •
dibular plane angle with mandibular retrusion.
Asymmetric mandibular excess
Torticollis (Wry Neck)
This type of asymmetry was previously called condylar hy-
It is a muscular disorder that affects flexion, extension, or perplasia. It is due to excessive unilateral growth of the man-
twisting of the neck muscles beyond their normal position. dible, which may affect the body, ramus and condyle. This
Mandibular asymmetry arises due to twisting of the head due spectrum of asymmetry includes Hemimandibular elonga-
to excessive muscular contraction (especially sternocleido- tion, Hemimandibular hyperplasia and hybrid type elonga-
mastoid muscle). In children, it is due to congenital factors tion (Obwegeser and Makek, 1986) (Table 2 and 3). The exact
such as increased intrauterine pressure during pregnancy or aetiology of this malformation is unknown, but it may occur
pressure during birth. In adults, it can be due to infection, due to the escape of growing tissues on one side from normal
tumours or trauma. Treatment of Torticollis includes surgical regulatory control (Eslami et al., 2003). Affected individuals
detachment of contracted muscles at an early age to release are metabolically normal with normal hard and soft tissue as
any growth restriction on the affected side (Ferguson, 1993).
160 Asymmetries
Table 2: Comparison between Hemimandibular Elongation & Hemimandibular Hyperplasia
Hemimandibular elongation Hemimandibular hyperplasia
Unilateral horizontal enlargement of mandible Unilateral three-dimensional enlargement of mandible terminat-
ing at symphysis of the affected side
Both horizontal and vertical components contribute to the abnor-
mal growth pattern.
Horizontal displacement of chin point to the unaffected Chin position mostly undisturbed
side
Dental midline usually displaced to the unaffected side Dental midlines usually coincident
Mandibular dental midline may coincide with chin point Dental centerline and chin are often undisturbed
but does not coincide with midfacial line
Mandibular rami lie at the same level bilaterally Increased ramal length and hyperplasia of the lower border of the
mandible on affected side
Body of the mandible displaced inferiorly and rotated medially
Normal alveolar bone height above inferior alveolar canal Increased alveolar bone height above inferior alveolar canal of
of affected side affected side
No compensatory transverse canting of the maxillary oc- Transverse canting of the maxillary occlusal plane due to over-
clusal plane eruption of maxillary dentition on affected side to compensate for
excessive mandibular overgrowth
Occlusal plane remains level No lateral open bite of buccal
segment
A unilateral lateral open bite on affected side if dental eruption
cannot keep pace with excessive vertical mandibular growth,
especially if tongue becomes interposed
Crossbite on unaffected side A unilateral lateral open bite on affected side if dental eruption
cannot keep pace with excessive vertical mandibular growth
Scissor bite on affected side
especially if tongue becomes interposed
Radiographic findings: Radiographic findings:
Elongation of the affected side of the mandibular body Increased vertical length of ascending ramus
Enlargement of condyle
Elongation and thickening of condylar neck
Rounded angle of mandible
Downward bowing of lower border of mandible on affected side
Increased height of mandibular body
Increased distance between molar roots and mandibular canal
Normal height seen on unaffected side
Excessive growth demarcated by abruptly stopping at midline of
symphysis
confirmed by histologic diagnosis. Females constitute 85% of Management of asymmetric mandibular excess
affected cases; the age of onset of this excessive growth dis-
order is during the mid to late teenage years, as mandibular In cases of progressive deformity, surgical intervention of the
growth progresses and becomes noticeable after the adoles- overgrown condyle is indicated even in young patients. Surgi-
cent growth spurt. It may be self-limiting or a progressive cal options are:
condition. • Excision of bone at the head of the condyle followed by
Asymmetries 161
Type I Broad proliferative zone cant of the occlusal plane.
Increased thickness of hyaline carti- • Pitch: Rotation of the dentition about a coronal axis.
lage Causes of dental midline asymmetry
Cartilage islands within the bone These include:
Type II Patchy distribution • Early loss of teeth
Reduced cartilage islands • Congenitally missing teeth
Type III Distortion of condyle
• Impacted teeth
Irregular hyaline cartilage masses ex-
• Single or multiple tooth crossbite causing functional
tend into cancellous bone of the con-
mandibular shift on closure
dyle or superficial articular layer
Type IV Condyle appears burned-out • Inappropriate extraction in case of crowding
• Removal of the condyle and condylar process fol- Class III subdivisions
lowed by reconstruction of the TMJ, either with a Subdivision refers to the Class III side. The treatment op-
costochondral junction transplant or with a free tions are:
graft (Boyne, 1989).
• In cases of crowding with a deviated maxillary mid-
• For adults, total joint replacement of the TMJ can be line, it is advisable to extract two lower premolars
performed. and a single upper premolar on the Class III side.
• If excessive growth stops spontaneously and the • In cases of deviation of the mandibular midline only,
condition stabilizes, jaw surgery is delayed until after it is advisable to extract only one lower premolar on
the adolescent growth spurt without involvement of the Class III side. The benefit of extracting a single
the TMJ. lower tooth instead of two is the better control of the
Mandibular displacements on closure lower midline and reduced requirement for asym-
metric elastics.
It is mainly due to transverse maxillary constriction or pre-
mature contacts. Mandibular asymmetry may develop due to
the shortening of the ramal height due to growth restriction Examination of asymmetry
on the side of the crossbite (Schmid et al., 1991).
These include:
Dental asymmetries
• Extraoral soft tissue examination includes assessing
It is considered the most challenging dental malocclusion deviations of the dorsum and tip of the nose, phil-
to correct (along with overjet) (Kokich, 1993); hence, it was trum of upper lip and midpoint of the chin about the
given a weighting of 4 in the Peer Assessment Rating (PAR) facial midline. It also contains extraoral examination
Index (DeGuzman et al., 1995). Dental asymmetries can oc- in which mandibular asymmetry is assessed from a
cur in three planes of space. frontal view, superior view (bird’s eye view) or infe-
• Yaw: Discrepancy of the dentition about a vertical rior view (worm’s eye view) to reveal the extent of
axis resulting in a dental midline asymmetry (Ack- the deviation.
erman et al., 2007). • Intraoral clinical examinations include assessing the
• Roll: Discrepancy in the transverse plane about a dental midlines relative to each other and the facial
sagittal axis is termed roll deformity and results in midline and assessing the mandibular displacement
162 Asymmetries
Table 4: Class II subdivisions and their management
Combination • Is found in about 20% Inter-arch mechanics aimed at correction of both arches
Class II subdivi- of cases
sion
• Features of both types
of class 2 subdivision
malocclusion
• Some tooth size
discrepancy found in
both arches
on closure. Upper and lower dental midlines should dimensions and quantification of facial asymmetry
be evaluated in centric relation and centric occlu- (Nute and Moss, 2000). Laser scans are used in plas-
sion. In mandibular deviation and if lower dental tic surgery to study the facial asymmetry (O’grady
midline coincides with the chin point, the skeletal and Antonyshyn, 1999).
origin of discrepancy is most likely. In the absence of
• Stereophotogrammetry is another non-invasive and
mandibular deviation and if the lower dental mid-
reproducible technique of imaging. It obtains 3D
line is not consistent with chin point, the dental ori-
images using multiple photographs of the same ob-
gin of difference is most likely. Cant in the maxillary
ject taken at different angles. It allows detection of
occlusal plane should also be assessed relative to the
changes in facial growth and development, gauging
inter-pupillary line using tongue spatula.
facial morphology and monitoring facial asymmetry
• Extraoral photographs, including frontal, profile over time.
and three-quarter profile views and the front view
• Ionising imaging includes:
of patient biting on a tongue spatula, can illustrate
transverse occlusal cant. Intraoral photographs 1. Panoramic radiograph that allows bilateral comparison
should also be taken in centric occlusion and centric of the mandibular ramus and condylar shape. However, the
relation in mandibular displacement. validity is poor due to the effect of patient positioning.
• Laser scanning is an applicable non-invasive proce- 2. Posterior-anterior cephalometric radiographs allow as-
dure that allows digitisation and comparison of im- sessment of left and right hard-tissue structures and skel-
ages and records more than 60,000 points in 10 sec- etal and dental midlines. Localisation of the asymmetry is
onds resulting in an accuracy of 0.5 mm (Moss et al., achieved by using a midsagittal reference plane.
1991). It allows examination of facial growth in three
3. Transcranial and transpharyngeal views of TMJ are used
Asymmetries 163
to analyse pathology, arthritic disease, and trauma to the in cases where the skeletal asymmetry is mild or accepted,
TMJ. and the atypical growth must have ceased. Dental midline
discrepancies can be camouflaged orthodontically by the fol-
4. Lateral cephalogram can identify vertical asymmetry in
lowing techniques:
the bilateral asymmetrical superimposition of symmetric
structures. A single ear rod is used in a natural head position • Asymmetric extraction patterns for correction.
for correct orientation in a patient with an altered ear posi-
• Asymmetric mechanics include asymmetric lace-
tion.
backs, push-pull mechanics and asymmetric use of
5. Computerised tomography provides the most detailed elastics.
visual aid to the skeletal morphology (Sievers et al., 2011).
• Asymmetric torque for correction of asymmetric
Cone beam computerized tomography images and 3D recon-
transverse relations.
structed images can help study developmental deformities
and locate the position of any bony asymmetry (White and 2. Surgical treatment
Pharoah, 2000).
• Corrective orthognathic surgery is indicated after
6. Radioisotope imaging such as short-lived gamma-emit- cessation of atypical growth. Pre-surgical orthodon-
ting isotope (Technetium 99m) is mainly indicated in Hemi- tics involves levelling and alignment accompanied
mandibular hyperplasia and Hemimandibular elongation by decompensation of arches. Correction of dental
cases. It is also used for imaging bones, salivary glands and midlines to their respective jaw (skeletal) midlines
investigation of tumour pathology (especially in the salivary is undertaken during the pre-surgical orthodontics,
glands). However, it is associated with excess radiation expo- while skeletal midlines are corrected through sur-
sure and false-negative results (Matteson et al., 1985). gery. Bilateral sagittal split osteotomy is performed
in cases of severe mandibular skeletal asymmetry. Le
• Magnetic resonance imaging can also be used to as-
Fort I osteotomy may be required to correct a trans-
sess soft tissue asymmetry.
verse occlusal cant which occurs due to compensa-
• Study models articulated with a facebow transfer tory maxillary growth. Post-surgical orthodontics
demonstrate the relationship of the jaws in 3 planes consists of detailing the occlusion and achieving in-
of space and allow assessment of the functional oc- terdigitation of the arches.
clusion in asymmetry cases.
• Distraction osteogenesis (DO) is indicated in severe
• Information obtained from CBCT/ CT scan can be asymmetric mandibular deficiency where ramus
used for stereolithographic printing models of the and body require lengthening, such as severe hemi-
facial skeleton. It is useful for planning surgery in facial microsomia or condylar fracture at an early
patients with severe facial asymmetry (Sailer et al., age causing severe restriction of translation on the
1998) (Kernan and Wimsatt, 2000). affected side (Tehranchi and Behnia, 2000)
• Special investigations such as incisional/ excisional • Adjunctive surgical procedures such as genioplasty
biopsies can be prescribed to reveal the nature of are indicated where the change in the chin’s repo-
hard or soft tissue pathology (fibro-osseous lesions sition is required in the vertical or transverse di-
or tumour-like lesions). mension. This is considered a very stable procedure
(Proffit et al., 1996). Implants or bone recontouring
Management of functional asymmetry
can be adopted to correct the asymmetric shape of
Occlusal adjustments can be performed to eliminate prema- the ramus or body of the mandible. Moreover, some
ture contacts that cause mild deviations of the mandible. An might even consider non-surgical soft tissue proce-
occlusal splint may be required to ‘deprogrammer’ habitual dures such as filler and BOTOX
displacements to aid diagnosis. Functional displacement
of the mandible due to a crossbite might require maxillary
expansion for correction. Maxillary expansion can be per-
formed using upper removable appliances with a midline ex-
pansion screw or fixed appliances incorporating a quad-helix,
auxiliary expansion arches or rapid maxillary expansion (Gill
et al., 2004).
Management of skeletal asymmetry
These include:
1. Orthodontic camouflage: This approach can be attempted
164 Asymmetries
Exam night review Traumatic factors: Condylar fractures and subsequent an-
kyloses and eventually asymmetry of the jaws (Proffit et al.,
General features
1980).
• Right side is commonly larger.
Functional factors: Centric occlusion to centric relation dis-
• Greater than 4mm of mandibular asymmetry is crepancies can lead to mandibular displacement on closure.
clinically noticeable (McAvinchey et al., 2014).
Idiopathic and iatrogenic factors
• Up to 2.2 mm of dental midline discrepancy is per-
Local factors
ceived as acceptable (Janson et al., 2011).
Classification of asymmetry
Aetiology of asymmetry
• Skeletal asymmetry affecting.
Environmental factors
• Muscular asymmetry
• Intra-uterine pressure and moulding
• Functional asymmetry secondary to TMJ dysfunc-
• Condylar hyper/hypoplasia
tion or a CO-CR shift.
• Excessive condylar growth
• Dental asymmetry
• Habits e.g. Thumb sucking
Hemifacial microsomia (HFM)
Developmental factors (Chia et al., 2008)
Congenital disorder →unilateral developmental defects in
• Hemimandibular elongation orofacial region.
• Hemimandibular hyperplasia Proposed Aetiologies for HFM
• Condylar hypo- or hyperplasia • Defect in proliferation and migration of neural crest
cells
• Hemifacial microsomia
• Hemorrhage of stapedial artery (Poswillo, 1973).
• Hemifacial hypertrophy
• Goosecoid (Gsc) - potential candidate gene for
• Hemifacial atrophy (Parry-Romberg syndrome)
Hemifacial microsomia (Kelberman et al., 2001).
• Achondroplasia
Clinical features of HFM
• Torticollis
• Mandibular asymmetry of varying severity.
• Unilateral cleft lip and palate
• Reduction in size or flattening of facial bones.
• Childhood fractures of the jaw
• Unilateral crossbite.
Pathological factors
• Disturbed tooth development.
• Tumors of orofacial region (e.g. Ameloblastoma
• Severely malformed or absent pinna of the ear.
arising in body and ramus of mandible, tumors of
condylar head including osteoma, osteochondroma, • Periauricular skin tags.
chondrosarcoma).
• Narrowed palpebral fissures.
• Cysts (e.g. Dentigerous cysts, keratocysts, lympho-
• Unilateral epibulbar dermoids.
epithelial cysts)
• Variable degrees of nerve palsy
• Fibrous dysplasia
• Cleft lip and palate, palatal and tongue muscle hypo-
• Infection (e.g. Dento-alveolar abscesses, acute par-
plasia and velopharyngeal insufficiency→ less com-
otitis)
mon.
• Decreased tonic muscular activity (cerebral palsy,
Management of HFM
muscular dystrophy, Muscle weakness syndromes)
• Growth modification using the hybrid functional
• Muscular atrophy due to damage to motor nerve
appliance.
• Condylar resorption due to juvenile rheumatoid ar-
• Reconstructive surgery→severe deformity.
thritis, post-steroid therapy and following orthogna-
thic surgery. Juvenile Rheumatoid Arthritis
Asymmetries 165
• It is a disease process that affects bone and cartilage. • It is characterised by overgrowth in the craniofacial
structures (including soft and hard tissues).
• In children with one to three affected joints, TMJ
is involved in 33% of cases, while in children with • Occlusion is also likely to be affected.
greater than four affected joints, TMJ is involved in
Examination of asymmetry
80% of cases (Ince et al., 2000).
• Extraoral clinical examination
• Progressive destruction of condyles results in short-
ening of ramus and downward and backward rota- • Intraoral clinical examinations
tion of the chin, which leads to chin deficiency and
• Non-ionizing imaging
anterior open bite.
• Ionising imaging
• Condylar resorption may occur faster on one side
than the other resulting in mandibular asymmetry • Radioisotope imaging
in two thirds to three-fourths of affected children. • Study casts
Treatment of Juvenile Rheumatoid Arthritis • Stereolithographic models
• TMJ replacement in severe cases. • Pathological special Investigations
• Functional appliances and any surgical procedure Management of functional asymmetry
which manipulates TMJ are not recommended.
• Occlusal splint
• Augmentation genioplasty
• Occlusal adjustments
• Surgical maxillary impaction
• Functional displacement of mandible due to cross-
Condylar resorption following orthognathic surgery bite requires orthodontic treatment (including max-
Predisposing factors: illary expansion) for correction.
• Preoperative temporomandibular joint dysfunction • Maxillary expansion.
(Hwang et al., 2004). Management of skeletal asymmetry
• Young and female patients (due to hormonal fac- Orthodontic camouflage: for acceptable skeletal asymmetry
tors)
• Asymmetric extraction patterns
• High mandibular plane angle with mandibular re-
trusion. • Asymmetric mechanics
Asymmetric mandibular excess • Asymmetric torque
• It is due to excessive unilateral growth of the man-
dible, which may affect its body, ramus and condyle.
Management of asymmetric mandibular excess
• In progressive deformity, surgical reduction/remov-
al of the affected condyle is indicated even in young
patients.
• Excision of bone at the head of the condyle followed
by recontouring or repositioning of the bony stump
into the glenoid fossa
• Removal of the condyle and condylar process fol-
lowed by reconstruction of TMJ either with a costo-
chondral junction transplant or a free graft (Boyne,
1989).
Hemifacial hypertrophy
• It is hypertrophy of one side of the face.
• It is mainly due to the asymmetric distribution of
neural crest cells.
166 Asymmetries
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Asymmetries 167
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168 Asymmetries
High Angle Cases
17
Written by: Mohammed Almuzian, Haris Khan, Awrisha Tariq
In this Chapter
1. Aetiology of high angle cases
2. Clinical features
3. Radiographical features
4. Clinical implications in treating high angle
5. Treatment considerations
6. EXAM NIGHT REVIEW
H igh angle in orthodontics refers to increased vertical pro-
• Increased overjet.
Radiographical features
portions of face. In cephalometric analysis, if vertical values
are above one standard deviation, then the case is considered The main cephalometric features of high angle cases include
high angle. Cephalometric values used to diagnose high angle increased mandibular inclination in relation to anterior cra-
are: nial base, excessive lower facial height, small posterior facial
• MMPA greater than 29˚. height and large gonial and mandibular plane angle. Other
structural features of high angle cases as per Bjork are (Ski-
• FMPA greater than 32˚. eller et al., 1984)(Björk, 1969):
• LAFH greater than 57%. • Decreased inter-molar and inter-premolar angle.
• SN-Mandibular plane greater than 36˚. • Decreased interincisal angle (acute).
• SN-Palatal plane greater than 10˚. • Increased lower anterior facial height.
• Sum of inner angles are greater than 400˚. • Forward inclination of the mental symphysis.
• Y-axis angle greater than 70˚. • Backward inclination of the condylar head.
• Jarabak ratio greater than 61%. • Steep curvature of the mandibular canal.
• Overbite depth indicator less than 68˚ (Fatima et al., • Prominent antegonial notch.
2016).
Clinical implications in treating high angle
Aetiology of high angle cases
These include:
High angle cases cover a number of conditions including long
face syndrome, backward growth rotations, anterior open • High angle patients can present with a reduced
bite and open bite tendency. The main aetiological factors are: overbite or an anterior open bite which is difficult to
control.
• Unfavorable vertical/ backward growth pattern.
• A steep occlusal plane in high angle cases is associ-
• Hereditary factors, e.g. increased tongue size and ated with higher anchorage demand compared with
abnormal growth pattern of mandible and maxilla. low angle cases.
• Thumb sucking habit, which causes an anterior open • The reduced bone quality (Johari et al., 2015) and
bite along with a backward rotation of the mandible the reduced buccolingual alveolar bone thickness
(Ngan and Fields, 1997). (Lee et al., 2018) explain the poor primary stabil-
• Tongue thrust habit. ity and high failure rate of miniscrews in high angle
cases.
• Prolonged mouth breathing, leading to over-devel-
opment of posterior dentoalveolar height. • High angle cases have a marked ANB discrepancy
(Class II skeletal pattern) due to downward and
• Orofacial matrices malfunction due to an imbalance backward rotation of the mandible. Clockwise ro-
between jaw posture, occlusion, eruptive forces and tation of the mandible increases the lower anterior
head position. This imbalance leads to a downward face height and lead to retroclination of the lower
and backward rotation of the mandible. incisors and subsequently lower labial segment
Clinical features of high angle cases crowding (Betzenberger et al., 1999). Therefore, any
treatment mechanics that might cause backwards
These include: rotation of the mandible should be avoided.
• Tapered facial type. • Short roots have been observed with a reduced
• Increased lower anterior facial height. crown/root ratio (Uehara et al., 2013).
18
Written by: Mohammed Almuzian, Haris Khan, Eesha Najam, Eesha Muneeb, Muhammad Qasim Saeed
In this Chapter
1. Aetiology of Anterior open bite (AOB) 19. Kim mechanics
2. Classification of AOB 20. Modified Kim mechanics
3. Incidence of AOB 21. Molar intrusion using skeletal anchorage
4. Predictors of skeletal open bite 22. Treatment considerations of AOB treated with
5. Features of skeletal open bite molar intrusion
6. Justifications for treatment of AOB 23. Rapid molar intrusion device (RMI)
7. Aetiology of AOB 24. Advantages and disadvantages of RMI
8. Digit Sucking Habit 25. Repelling magnets for the treatment of OAB
9. Long term effects of pacifier and dummy suck 26. Orthognathic option for management of skeletal
ing habit AOB
10. Management of digit-sucking habits 27. Factors contributing to skeletal relapse
11. Types of removable habit breakers 28. Adjunctive procedures
12. Types of fixed habit breakers 29. Stability of AOB treatment
13. Management of mouth breathing 30. Causes of relapse
14. Management of secondary tongue thrust 31. Retention of treated AOB cases
15. Myofunctional therapy for the treatment of AOB 32. Methods for retention
16. Combined myofunctional and extraoral appli 33. Difficulty associated with the treatment of AOB
ance combination therapy 34. Posterior open bite
17. Extraoral appliance for management of AOB 35. EXAM NIGHT REVIEW
18. Treatment principles in the management of AOB
using fixed appliances
A OB is defined as a vertical discrepancy with no contact
•
canine but does not include premolars
Compound open bite – when the open bite extends
between anterior teeth in centric relation or lack of vertical
overlap of the upper incisors’ with the lower incisor crowns from premolar to premolar but does not include mo-
when the posterior teeth are in occlusion (Houston et al., lars
1992). • Infantile open bite – open bite which includes mo-
Openbite can also be described as a vertical space between lars
maxillary and mandibular incisors perpendicular to the 4. Based on the morphology of the skeletal pattern (Kim,
functional occlusal plane and is quantified by overbite mea- 1974), which include:
surement from the opposing dentition with the largest verti-
• Dentoalveolar open bite – when the mandible ap-
cal discrepancy.
pears to be normal
Aetiology of AOB
• Skeletal open bite - when the mandible appears ab-
The aetiology can be skeletal, dental or soft tissue or a com- normal
bination. A severe open bite is due to a marked divergence of
5. Based on aetiological and skeletal considerations, (Rich-
skeletal planes. The range of severity varies, as it may be local-
ardson, 1981) include:
ised, affecting only a few teeth with a below-average overbite,
an edge-to-edge occlusion, or a definite space between the • Transitional open bite
upper and lower incisors.
• AOB due to habits such as digit sucking
• Dental (functional) anterior open bite is localised
• AOB due to local pathologies such as cysts, dilacera-
to anterior teeth in occlusion. The skeletal vertical
tions, and ankylosis
proportions and surrounding soft tissues are usually
normal. • AOB due to skeletal pathologies (de novo open bite)
such as cleft palate, craniofacial dysostosis, cleido-
• Skeletal open bite occurs when the primary aetiolo-
cranial dysostosis and achondroplasia
gy of an anterior open bite is a hyperdivergent facial
growth pattern, which is an excessive divergence of • Non-pathological skeletal group (ab initio open
the maxillary, occlusal, and mandibular planes about bite)
each other and the anterior cranial base (Sassouni,
• AOB due to morphology and behaviour of the
1969). It may also be referred to as apertognathia
tongue and lips
(Naini, 2011). A skeletal open bite may be caused
either by forwarding rotation (upward tipping) of a 6. Other classification (Rakosi and Jonas, 1993) include:
palatal plane or by downward tipping of the man- • Pseudo open bite – occurs in the presence of incisor
dibular plane. protrusion
Classification of AOB • Infantile open bite - involves all teeth, including mo-
These include: lars
1. Based on aetiology: developmental or acquired (Shira, • Iatrogenic open bite - occurs due to erroneous orth-
1961) odontic treatment
2. Based on site (anterior or lateral) and pattern (alanting or Incidence of AOB
angulated) (Thoma, 1943) The prevalence of AOB increases to 36.3% when the ante-
3. Based on severity and extent of involvement, (Worms et rior open bite is associated with sucking habits in the mixed
al., 1971) include: dentition (Cozza et al., 2005), it ranges from 17% to 18% of
children in the mixed dentition (Cozza et al., 2005, da Silva
• Transitional open bite – open bite that occur dur-
Filho et al., 1990, Tausche et al., 2004). AOB is more com-
ing mixed dentition when the permnant incisors are
mon in Africans and Africa-Caribbeans with a prevalence of
erupting.
5% (Noar and Portnoy, 1991). There is a marked difference
• True open bite – open bite without any vertical over- in the prevalence of dental open bite among black and white
lap as well as no contact between between upper and children in the USA, affecting approximately 16% of the black
lower incisors population and only 4% of the white population (Kelly et al.,
1973). In Scotland, the incidence is 4% amongst adults (Todd
• Simple open bite – when the open bite is 1 mm or
and Whitworth, 1974). In the UK, open bite affects 4% of
greater in centric relation extending from canine to
children by 9 years of age. However the incidence falls to 2%
• Over eruption of posterior teeth • Chronic allergic rhinitis associated with non-nu-
tritive sucking habits or bottle-feeding have been
• Proclination of incisors linked to anterior open bite and a posterior crossbite
4. Pathological factors such as: malocclusion in preschool children aged 4 to 5 years
(Vázquez-Nava et al., 2006). Studies of individuals
• Idiopathic condylar resorption after orthognathic with obstructive sleep apnea (Kikuchi et al., 2002)
surgery – risk factors include a female patient with and mouth breathing (Juliano et al., 2005) have
mandibular retrognathism associated with a high found a distinctive cephalometric pattern, which in-
mandibular plane angle, pretreatment condylar at- cludes long face and increased lower anterior facial
rophy, and undergoing posterior condylar displace- height, suggesting a hyper divergent pattern of skel-
ment and upward and forward rotation of the man- etal open bite (Frankel and Frankel, 1983). Accord-
dible at the time of surgery (Gill et al., 2008). ing to some studies, prolonged mouth-breathing due
• Neuromuscular conditions such as cerebral palsy to tonsillar or adenoidal obstruction may be a con-
and muscular dystrophy – where poor soft tissue tributory factor towards malocclusion, but it is not
tone may contribute to posterior growth rotation of thought to be the main causative factor (Sandler et
the jaws and an appreciable anterior open bite. al., 2011) and the effects of the mode of breathing on
facial morphology were unsupported according to
• According to Gershater, there is a high incidence Shanker 2004 (Shanker et al., 2004). An association
(32.3%) of anterior open-bite in mentally retarded between open bite, respiratory pattern, sleep respira-
and emotionally disturbed children where problems tory disturbance and snoring still needs to be deter-
in controlling the tongue at rest or in function are mined (Ali et al., 1993, Gottlieb et al., 2003, O’Brien
experienced. (Gershater, 1972) et al., 2004, Smedje et al., 2001)
• Systemic conditions such as systemic lupus erythe- • Masticatory muscles: A relationship between weak
matosus resulting in condylysis; cleft palate. musculature and a hyperdivergent growth pattern
5. Iatrogenic factors such as: (Proffit and Fields, 1983, Ringqvist, 1973). Mastica-
tory muscles in long face patients associated with
• Poorly controlled extrusive orthodontic forces on anterior open bite are likely to have low volume
the posterior teeth, resulting in extrusion of upper (Rowlerson et al., 2005). The smaller muscle fibers
molars and opening of the bite anteriorly in high (shorter and thinner masseter muscles) can gener-
angle cases. ate less bite force. In contrast, increasing volume of
• Use of anterior bite plane in cases with a reduced muscle, long thick masseter muscle with larger fibres
overbite. is associated with anterior growth direction, larger
posterior face height, and deep bite in short face in-
6. Soft tissue factors such as: dividuals (Proffit et al., 1983, Benington et al., 1999,
• Nasorespiratory function and head posture: Pos- Hunt and Cunningham, 1997, Ingervall and Helki-
tural changes to the head due to chronic partial na- mo, 1978, Kiliaridis et al., 1995, Corruccini, 1984).
sal airway obstruction (Solow and Tallgren, 1976), • Tongue size, resting position and/or activity includ-
hypertrophic nasopharyngeal tissues (adenoids, ing:
tonsils) or enlarged lymphatic tissue (Subtelny and
19
Written by: Mohammed Almuzian, Haris Khan, Awrisha Tariq
In this Chapter
1. Basic terminologies
2. Prevalence
3. Aetiology deep overbite
4. Principles of deep incisor overbite reduction
5. Method of treating DOB
6. Management of overbite
7. EXAM NIGHT REVIEW
O verbite (OB) describes the vertical overlap of the upper
gulum.
Principles of deep incisor overbite reduction
and lower incisors measured perpendicular to the occlusal
plane with the posterior teeth in the occlusion (BSI 1983). These include:
OB is measured perpendicular to the occlusal plane in mm or
• True incisor intrusion is mainly indicated in an
expressed as a ratio. The normal range for the maxillary inci-
adult patient with excessive maxillary incisors show-
sors to vertically overlap the mandibular incisors is 2–4 mm,
ing at rest and a patient with long lower facial height
or one-third to one-half of mandibular incisors crown height.
with over erupted incisors.
Basic terminologies
• Levelling of the arch through molar and premolar
These include: eruption and extrusion (Cobourne and DiBiase,
• Deep bite: When the maxillary incisors overlap, the 2015). Keeping in mind that the condyle will com-
mandibular incisor crowns vertically by greater than pensate for the extrusion in a growing patient and
one-half of the lower incisor crown height. maintain the anterioposterior relationship, but in
the adult, the condyle does not compensate for that
• Complete: There is contact between incisors or the (McDowell & Baker, 1991). however, the slight hing-
incisors and opposing mucosa. ing open of the mandible in adults, associated with
• Incomplete: if there is no contact between incisors molar extrusion, seems to be stable due to the ten-
or the incisors and opposing mucosa. dency to small continued vertical growth found in
adults (Behrents 1986).
• Traumatic overbite: When the increased overbite is
causing trauma to the upper or lower mucosa. Up- • Incisor proclination or relative incisor intrusion
per incisors mainly cause trauma to the lower labial (Ireland et al., 2016). Eberhart et al. (1990) stated
mucosa, especially in the case of class II div 2. In that 5 degrees of incisor proclination reduced the
contrast, the lower incisors can cause upper palatal overbite by 1 mm on average.
mucosa in the case of class I div and div II. • Distal tipping of posterior teeth
Prevalence • Surgery to change the anteroposterior and vertical
Worldwide, the prevalence is 11.13 % in mixed dentition and relationship.
14.98% in the permanent dentition (Alhammadi, 2018). Consideration factors for the method of treating DOB
Aetiology deep overbite These include:
These include: • Age and the remaining growth affect the degree of
• Skeletal and growth factors: A reduced lower face incisor show. It is preferable to accept slightly in-
height in conjunction with a Class II jaw relation- creased incisor show in the growing patient since
ship results in the absence of an occlusal stop to the soft tissue maturation would mask some of the un-
lower incisors, which subsequently over-erupt lead- derlying problems with ageing
ing to an increased overbite (Pancherz et al., 1997). • Patient compliance and concerns
Forward growth rotation, i.e. counter-clockwise
(average -7°), can cause skeletal deep bite leading • Vertical height relationship: For instance, it is rec-
to decreased anterior lower face height or increased ommended to avoid posterior teeth extrusion in
posterior face height (Nielsen, 1991). high angle cases.
• Soft Tissues such as high lower lip line (Nicole 1954, • Faial profile: It is recommended to avoid relative in-
Ridley 1960), hyperactive or “strap-like” lower lip trusion (proclination of incisors) in full or convex
(Lapatki et al., 2002), and hyperactive Mentalis mus- profile.
cle (Karlsen, 1994). These soft tissue factors result in • If the main aim of the treatment is to reduce the
deep bite by retroclination of the lower incisor. amount of incisor show, then absolute intrusion is
• Dental factors such as overeruption of the incisors, indicated. Generally, the incisors show they depend
long central and short lateral incisors, which results on the following factors: Lip length, crown height,
in the lateral incisors ‘escaping’ from the effects of lip activity, gingival height and level and the degree
the lower lip force, increased crown root angle of the of anterior maxillary height.
upper incisor, known as the Collum angle (McIntyre • Incisor inclination at the start of the treatment: If
and Millett, 2003), and thin incisors with small cin- the incisor is retroclined, deep bite management via
References
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Exam night review dontics, Elsevier Health Sciences.
Deep bite represents a condition when the maxillary incisors HOLDAWAY, R. A. 1952. Bracket angulation as applied to the
overlap the mandibular incisor crowns vertically by greater edgewise appliance. The Angle Orthodontist, 22, 227-236.
than one-half of the lower incisor crown height. Worldwide, HOUSTON, W. J. B. 1989. Incisor edge-centroid relationships and
the prevalence is 11.13 % in mixed dentition and 14.98% in overbite depth. European Journal of Orthodontics, 11, 139-143.
the permanent dentition (Alhammadi, 2018).
INGERVALL, B. & THILANDER, B. 1974. Relation between facial
Aetiology deep overbite morphology and activity of the masticatory muscles. J Oral Reha-
bil, 1, 131-47.
• Skeletal and growth factors (Pancherz et al., 1997)
KIM, Y. H. 1974. Overbite depth indicator with particular refer-
• Soft tissues factors (Nicole 1954, Ridley 1960) ence to anterior open-bite. American Journal of Orthodontics and
Dentofacial Orthopedics, 65, 586-611.
• Dental factors (McIntyre and Millett, 2003)
MILLETT, D. T., CUNNINGHAM, S. J., O’BRIEN, K. D., BEN-
Principles of deep incisor overbite reduction SON, P., WILLIAMS, A. & DE OLIVEIRA, C. M. 2006. Orthodon-
• True incisor intrusion tic treatment for deep bite and retroclined upper front teeth in
children. Cochrane Database Syst Rev, Cd005972.
• Levelling of the arch (Cobourne and DiBiase, 2015).
NAHOUM, H. I. 1977. Vertical proportions: a guide for prognosis
• Incisor proclination or relative incisor intrusion and treatment in anterior open-bite. Am J Orthod, 72, 128-46.
(Ireland et al., 2016). NAINI, F. B., GILL, D. S., SHARMA, A. & TREDWIN, C. 2006.
• Distal tipping of posterior teeth The aetiology, diagnosis and management of deep overbite. Dent
Update, 33, 326-8, 330-2, 334-6.
• Surgery to change the anteroposterior and vertical
NIELSEN, I. L. 1991. Vertical malocclusions: etiology, develop-
relationship.
ment, diagnosis and some aspects of treatment. Angle Orthod, 61,
Management of overbite 247-60.
• Upper removable appliance (URA) (Millett et al., PROFFIT, W. R., FIELDS JR, H. W. & SARVER, D. M. 2006. Con-
2006). temporary orthodontics, Elsevier Health Sciences.
• Extraoral traction (Linge and Linge 1983). SKIELLER, V., BJORK, A. & LINDE-HANSEN, T. 1984. Predic-
tion of mandibular growth rotation evaluated from a longitudinal
•
Dahl appliance (Cobourne and DiBiase, 2015, implant sample. Am J Orthod, 86, 359-70.
Björk, 1969).
• Appliance selection
• Fixed appliance settings
• Continuous rigid archwires
In this Chapter
1. Aetiology and profile
2. Features of low angle cases
3. Predictors of low angle
4. Principals of treatment
5. Methods to reduce overbite
6. The Dahl concept
7. EXAM NIGHT REVIEW
T he decreased vertical proportion (short face) charac-
Predictors of low angle
These include Bjork’s 7 structural signs that identify low angle
terised by deep bite is called low angle. In a cephalometric
analysis of a low angle patient, the majority of ceph values are cases (Björk, 1969):
lower from standard deviation: • Decreased lower AFH.
• Maxillary mandibular plane angle (MMPA) lesser • Increased intermolar and interpremolar angle.
than 21.
• Increased interincisal angle.
• Frankfort mandibular plane angle (FMPA)lesser
• Forward inclination of the mental symphysis.
than 22.
• Forward inclination of the condylar head.
• SN-mandibular plane lesser than 28˚.
• The curvature of the mandibular canal is greater
• SN-palatal plane lesser than 5˚.
than the mandibular contour.
• MMA angle is greater than 29˚.
• The lower mandibular border is rounded anteriorly,
• Y-axis angle lesser than 62˚. concave at the angle, and has an absent antegonial
• Jarabak ratio is greater than 64%. notch.
21
Written by: Mohammed Almuzian, Haris Khan, Maham Batool,Taimoor Khan, Rim Fathalla, Lubna
Almuzian, Dalia El-Bokle
In this Chapter
1. Classification of hypodontia 22. Evidence summary
2. Candidate genes in hypodontia 23. EXAM NIGHT REVIEW
3. Incidence of hypodontia
4. Aetiology and theories of hypodontia
5. Clinical presentation of hypodontia
6. Malocclusion features of hypodontia patients
7. Indications for treatment
8. General treatment principles
9. Options for treatment
10. Auto-transplantation
11. Space closure
12. Problems and solutions of cuspid substitution
13. Benefits of cuspid substitution
14. Points to consider during space closure
15. Reopen or redistribute space
16. Space opening and prosthetic replacement
17. Interim prosthesis of a space of a missing tooth
18. Types of final restorations
19. Criteria for implant placement
20. Success of dental implants
21. Treatment options for absent premolars
210 HYPODONTIA
Hypodontia is the developmental absence of one or more Table 1: Syndromes associates with hypodontia
teeth, excluding third molars (Goodman et al., 1994), also
known as selective tooth agenesis. Syndrome Associated gene(s)
HYPODONTIA 211
dontia occurs in around 0.25% (Nieminen et al., 1995, Sarnas als (Zilberman et al., 1990). Diminutive laterals are
and Rune, 1983). Prevalence of hypodontia is high in Africa often present in cases of palatally impacted canines
13.4% followed by Europe 7%. Asian and Australians have (Brin et al., 1986). A meta-analysis found that pa-
a similar prevalence at 6.3%. The lowest prevalence of 4% tients with unilateral diminutive shaped incisors
was reported in Latin America and Caribbean (Khalaf et al., have a high chance of agenesis (55%) of the lateral
2014). However, another systematic review and meta-anal- incisor on the opposing side (Hua et al., 2013).
ysis found no difference in prevalence among population of
• Lower incisors more commonly absent in the Asian
various ethnicities and geographic location (Rakhshan and
population, whilst the incidence among Caucasians
Rakhshan, 2016). In the UK population, the incidence of hy-
is 0.2% (J Neal and E Bowden, 1988).
podontia is 5.3-5.6% (Polder et al., 2004).
In Caucasians, the most commonly missing teeth after third
3. Gender variation: Hypodontia is more frequently report-
molars are lower second premolars > upper lateral incisors >
ed in females (Fekonja, 2005b, Khalaf et al., 2014). Females
upper second premolars > lower central incisors (Larmour et
to male ratio has been reported as F:M = 3:2 (Larmour et al.,
al., 2005). In some Asian populations, lower central incisors
2005, Rolling, 1980). The incidence in males is 4.6%, and in
are reported to be commonly missing.
females 6.4% (Polder et al., 2004).
Aetiology and theories of hypodontia
4. Jaw and side of occurrence: Increased incidence of miss-
ing teeth has also been reported in the maxilla (Sisman et al., A series of molecular regulatory factors and pathways are in-
2007) and in the mandible (Kirzioglu et al., 2005, Rolling, volved in tooth development. Factors such as FGF, BMP and
1980). No difference in right or left side predilection has been Wnt signaling pathway take part in epithelial-mesenchymal
found (Sisman et al., 2007), but some studies reported an in- interactions that are required for normal development of
creased incidence on the left side (Wisth et al., 1974, Roll- teeth. Any disturbance in these pathways may lead to tooth
ing, 1980), while others found a right sided predominance agenesis (Zhu et al., 1996). Several theories have been pro-
(Fekonja, 2005b). posed including:
5. Unilateral vs bilateral hypodontia: Overall, unilateral 1. Evolutional theory: Evolution of humans has resulted in a
missing teeth are more common, however, upper lateral in- decrease in size of jaws and number of teeth present in these
cisors are more commonly missing bilaterally (Chung et jaws (Vastardis, 2000). Generally, mesial teeth are more de-
al.,2008, Polder et al.,2004). Unilateral missing teeth are more velopmentally stable than teeth at distal end of series (Hob-
common in the case of the upper and lower second premolars kirk et al., 2010)
(Polder et al.,2004)
2. Anatomical theory: Dental lamina of teeth that are pres-
6. Sequence of hypodontia: Teeth that are present at the end ent at fusion regions of jaw bones or embryological processes
of each series are more susceptible to agenesis. It has been (Al-Ani et al., 2017a), are more susceptible to environmental
hypothesized that terminal teeth form at last in each tooth defects (Svinhufvud et al., 1988). Another theory is that the
series; thus, they can fall below the threshold that is required areas which developed at a later stage are more susceptible to
for normal dental development (Thesleff, 1996). Mesial teeth tooth developmental disturbances (Kjær et al., 1994).
are more developmentally stable than teeth at the distal end
3. Environmental theory includes (Al-Ani et al., 2017b):
of a series (Hobkirk et al., 2010). Some believe that these teeth
develop from two embryological origins, hence, they are at i. Systemic disruption of dental lamina by:
high risk of being missing (Al-Ani et al., 2017a). In summary: • Chemotherapy and radiotherapy in infancy (Parkin
• Third molars are the most commonly absent teeth et al., 2009, Näsman et al., 1997).
with an incidence of 25-35% (Peck et al., 1996). • Infection e.g. rubella infection (Cameron and Samp-
• Premolars can form as late as 9 years of age. Lower son, 1996).
5s are the most commonly absent (2.6%), followed • Drug interaction e.g. thalidomide (Gilbert-Barness,
by upper 5s then 4s (Wisth et al., 1974). Peck has re- 2010).
ported a 3% incidence of missing second premolars
(Peck et al., 1996). • Toxin (Brook, 2009)
• Canines, first and second molars are rarely missing ii. Localised disruption of dental lamina by:
(Symons et al., 1993) • Trauma, such as fracture of alveolar process (Brook,
• Absent maxillary lateral incisors occur in 2% of the 2009)
population (Peck et al., 1996). Familial tendency has • Cleft of alveolus resulting in transection of dental
been found for both diminutive and missing later- lamina
212 HYPODONTIA
• Nutritional deprivation e.g. insufficient calcium in • Upright incisors
diet.
• Generalized spacing and rotation of teeth adjacent
4. Genetic factors: Polygenic multifactorial model of aetiol- to the missing teeth.
ogy has been proposed as an aetiology for hypodontia, with
• Over-erupted incisors
many studies reporting a strong influence of genetic factors
on hypodontia. Twin studies demonstrated the autosomal • Increased overbite
dominant inheritance with incomplete penetrance and vari-
D. Dental features such as:
able level of expressivity (Cobourne, 2007a). Non-syndromic
hypodontia has a variable mode of inheritance, and can be • Enamel hypoplasia
autosomal dominant, autosomal recessive or autosomal sex • Microdontia (Graber, 1978) or conical / reduced
linked (Cobourne et al., 2012). Almost 300 genes are involved crown morphology of permanent teeth present
in the development of the dentition. Some of the genes most (Brook, 1984)
frequently associated with non-syndromic hypodontia are
presented in table 1. • Molar taurodontism
Clinical presentation of hypodontia • Short rooted teeth.
Clinically, patients with hypodontia may present with (Gill • Absent primary tooth
and Barker, 2015): • Prolonged retention of primary teeth (Kurol and
• Retained primary teeth, Thilander, 1984).
• Infra-occluded primary teeth, • Ankylosed primary teeth,
• Ankylosed primary teeth, • Infra-occlusion of primary teeth (Kurol and Thilan-
der, 1984).
• Absent primary tooth,
• Ectopic eruption or impaction of the adjacent teeth,
• Delayed / asymmetric eruption of permanent teeth, particularly maxillary canines. Up to 5% of those
• Conical / reduced crown morphology of permanent with absent lateral incisors may present with maxil-
teeth present, and lary canine impaction. (Brin et al., 1986)
• Lack of alveolar bone growth in three planes of • Transposition (Peck et al., 1996)
space. • Delayed and asymmetric eruption of permanent
Malocclusion features of hypodontia patients teeth. The second premolars are particularly prone
to a delay in dental development, and may not be
The dental, occlusal, alveolar and skeletal features of patients
visible radiographically until the age of 9 years.
with hypodontia include:
Hence, a diagnosis of their absence should be made
A. Skeletal features (depending on the severity of maloc- with caution before this age. (Wisth et al., 1974)
clusion) such as:
• Lack of alveolar bone growth in three planes of
• Retrognathic and hypoplastic maxilla (Wisth et al., space.
1974, Hobkirk et al., 1995).
Indications for treatment
• Reduced MMPA and reduced vertical dimensions.
Several indications were proposed for treating hypodontia
(Taju et al., 2018).
including (Shaw et al., 1980):
• Low mandibular plane angle associated with re-
• Functional needs: Hypodontia has an adverse im-
duced lower anterior facial height and protrusive
pact on quality of life measures (Akram et al., 2011,
lips (Chung et al., 2000).
Akram et al., 2013, Wong et al., 2006)
B. Alveolar features (Cobourne and DiBiase, 2015) such
• Aesthetic needs
as:
• Dental health problems including food impaction
• Lack of alveolar bone
due to tipped or drifted teeth, traumatic over bite
• Fairly flat palatal vault which results in reduced and infraoccluded primary teeth
anchorage capacity of upper removable appliances,
General treatment principles
Nance palatal arch or implant placement.
Inter-disciplinary treatment involving orthodontist, prosth-
C. Occlusal features (Fekonja, 2005b) such as:
HYPODONTIA 213
odontist, oral surgeon and restorative dentist is necessary sor (U1) and canine (U3). Commonly, restorative
(Stevenson et al., 2013, Hobkirk et al., 2010), taking into con- dentists prefer to have more space between U2 and
sideration several factors such as: U3.
A. Complications /difficulties with treatment: The follow- • Where should U2 be positioned bucco-lingually: to-
ing complications are encountered while treating cases with ward the labial, in the centre of the ridge, or toward
hypodontia (Grahnén, 1956b): the lingual? Depend on the type and thickness of fi-
nal restoration.
• Aesthetic impact of treatment
• Where should U2 be positioned inciso-gingivally?
• Increased overall cost of treatment
This relationship is determined by the position of
• Increased treatment time the gingival margins.
• Anchorage difficulties 4. Evaluate gingival aesthetics.
• Poor root parallelism for implants 5. Determine space required by golden proportion, universal
mesio-distal width, contra lateral-tooth size or Bolton analy-
• Risk of relapse e.g. spaces reopening
sis (Bolton, 1958).
• Atrophy and loss of bone
6. Provision of space to facilitate restorative treatment.
• Compromised treatment outcome: Common issues
7. Take progress radiographs, and measure the space with
faced in treating these patients include space man-
the implant T ruler.
agement, uprighting and aligning teeth, manage-
ment of the deep overbite, and retention (Carter et 8. Occlusal adjustment.
al., 2003).
9. Interact with restorative dentists during finishing.
B. Treatment factors: The following factors should be con-
Options for treatment
sidered (Hobkirk et al., 1995):
These include (Gill and Barker, 2015):
• Age
A. No active treatment: No treatment is necessary if there is
• Medical history
no malocclusion associated and the patient is satisfied with
• Patient’s opinion and co-operation his/her dentition, or unwilling to commit to lengthy and
costly treatment (Kokich and Kinzer, 2005).
• Facial profile
B. Interceptive treatment: General dentists play an important
• Smile line
role in early detection of developmentally missing incisors.
• Gingival line Early extraction of primary canine to prevent / intercept
• Malocclusion and extent of hypodontia the associated impaction of the maxillary canine has been
advocated in many studies (Parkin et al., 2017). Intercep-
• Intra- and inter-arch relationships tive extractions of primary teeth are advised in the mixed
• Dental features size, shape, colour of the adjacent dentition stage for maximum space to be closed spontane-
teeth ously (Lindqvist, 1980), maintaining alveolar bone for future
implant placement (Kokich et al., 2011, Fekonja, 2005a).
• Clinical situation of retained teeth. However, retention of the primary incisor or canine can be
C. Sequence of treatment of functional benefit as the primary teeth will maintain the
alveolar bone for orthodontic treatment and future implant
Both orthodontists and restorative dentists should estab- placement (Carter et al., 2003).
lish realistic objectives rather than idealistic, which include
(Spear et al., 1997): C. Auto-transplantation: It can be recommended if a donor
premolar is available, to transplant to the recipient (hy-
1. Create a diagnostic set-up (set up of current dentition) or podontia) site, especially in cases of multiple missing maxil-
Kesling set up (repositioning of dentition). lary incisors (Zachrisson et al,2004). Criteria for auto-trans-
2. Determine the sequence of orthodontic treatment. plantation of premolars to missing incisors site (Andreasen
et al., 1990b) are:
3. Building-up malformed teeth and answering the follow-
ing questions: • Roots of the donor premolars should be less than ¾
formed.
• Where should the maxillary lateral incisor (U2) be
positioned mesiodistally relative to the central inci- • Multiple missing incisors.
214 HYPODONTIA
• Procedure is undertaken by skilled surgeons. Problems and solutions of cuspid substitution
• Adequate space in the arch (Zachrisson et al., 2004). Although cuspid substitution offers several advantages over
space opening, it is associated with some obstacles (Table 3).
• No jiggling contacts between donor tooth and op-
posing teeth during post-surgical recovery phase Benefits of cuspid substitution
(Andreasen et al., 1990a).
These include:
• Use of 3D printed donor tooth to facilitate surgical
• Cuspid substitution is considered the least invasive
procedure.
option when compared to tooth-supported restora-
Advantages of auto-transplantation (Aslan et al., 2010) tions or implant replacement.
These include: • Evidence has shown that implant-supported re-
placement is not immune to complications such as
• In growing children, the transplanted tooth main-
progressive resorption of the labial cortical plate,
tains growth and development of the alveolar ridge,
progressive infraocclusion secondary to long-term
and also provides a permanent solution to agenesis
facial growth, gingival darkening, gingival recession
of teeth.
as well as the possible need for several years of post-
Successfully transplanted premolars appear to treatment maintenance and probably bone augmen-
continue erupting and aesthetics is good when restored with tation (Thilander, 2000, Robertsson and Mohlin,
porcelain veneer crowns or full porcelain coverage. 2000).
D. Space closure: Factors favouring the decision to close the • Also, the difficulty of matching natural tooth color
space when upper lateral incisors are missing are listed in and translucency with an implant-supported pros-
table 2. thesis has been reported (Zachrisson et al., 2004,
Kokich and Kinzer, 2005).
Table 2: Factors favouring the decision to close the space of missing upper lateral incisor
Factors Examples
General factors Patients willing to undergo a possibly longer treatment duration and enameloplasty of the canine
and premolar.
Patients refusing artificial teeth/prosthetic restorations; bridges or partial denture, or implants.
Macro-aesthetic factors Convex facial profile or Class II skeletal and dental relationships.
Bimaxillary protrusion requiring extraction for profile improvement.
Class II malocclusion with redundant overjet.
Mini-aesthetic factors Normal or increased tooth-gingival display during smiling.
Micro-aesthetic factors Small or average sized canine.
Favorable light color of canine.
Adequate attached gingiva on the canine.
Optimum alveolar bone width for canine mesialization.
Intra- and inter-maxillary Bilateral absence of lateral incisors.
factors
Unilateral agenesis of lateral incisor with a contralateral peg-shaped tooth.
Crowding requiring lower premolar extraction.
Minimal space left for the missing lateral incisors.
Proclined or normally-inclined upper incisors.
HYPODONTIA 215
Table 3: List of potential problems and solutions during canine substitution
Problems Solutions
Size mismatch due to large substituting canines and small premolars. Selective reduction and/or addition
Occlusal interference of the upper canine’s cingulum and the upper
premolar’s palatal cusp with opposing teeth.
Interarch tooth size discrepancy
Lack of canine eminence Hybrid bracket prescription
Lack of root parallelism between the adjacent teeth subsequent to Wire bending and detailing
space closure
Root resorption subsequent to the contact between the buccal roots
of the premolars and the buccal cortical bone
Improper gingival margin levels of the canines and premolars Hybrid bracket positioning
Wire bending and detailing
Gingivoplasty
Space reopening (relapse) Long-term bonded retainer
Extending retainer from first premolar to first premolar
and supplement with a removable night time retainer
(Zachrisson et al., 2011)
Dark color of the canine Vital bleaching
Thin porcelain veneer
High anterior anchorage demand, especially in Class III cases Protraction facemask
Profile flattening due to excessive uprighting of upper incisors during Temporary anchorage devices either alone or as part
space closure of an auxiliary appliance system such as Benefit system
(Wilmes et al., 2015, Amm et al., 2019)
Hybrid bracket prescription
Pulp sensitivity/exposure due to reshaping Adequate cooling & incremental reduction
Fluoride varnish for sensitivity
• It has been proven that the alveolar bone height can *Compensated bracket positioning for space closure treat-
be preserved through the early mesial movement of ment option
the canine (Zachrisson, 2007) with a minimal det- These include:
rimental effect on occlusal function (Nordquist and
McNeill, 1975). Compensated occlusal-gingival position of brack-
• Not only can cuspid substitution avoid possible im- ets: Two factors affect the choice for vertical canine and
plant failures and complications, but it can also re- premolar bracket positioning in canine substitution cases;
duce treatment time and cost with higher patient these are the lip line and the gingival condition (biotype &
probing depth). In cases of a high upper lip line or gummy
• satisfaction compared to prosthetic replacement
smile, the canine can be bonded more gingival to allow its
(Robertsson and Mohlin, 2000).
extrusion, bringing its gingival margin 0.5mm incisal to the
• According to Schneider et al. (Schneider et al., upper central’s, and its reduced incisal edge 0.5-1mm cervi-
2016), orthodontists and dentists rank cuspid sub- cal to that of the central. The first premolar can be bonded
stitution and implant-supported replacement as as usual occlusogingivally. A gingivectomy or surgical crown
equally pleasing esthetically, while laypeople prefer lengthening is performed to simulate the longer cuspid
canine substitution (Kokich and Kinzer, 2005). crown and provide ideal gingival aesthetics of high, low,
high from central incisors to canine, respectively (Zachris-
son, 2007).
216 HYPODONTIA
Canine and premolar brackets prescription for space closure treatment option
Options for Canines
Bracket* (Torque ˚ / Tip˚) Advantages Disadvantages
Ipsilateral U1 bracket 1. Adequate palatal root torque. 1. Labial enameloplasty is required
OTT=ETT (+17˚/+4o)
2. Suitable if no mesialization is required. 2. Labial offset bend may be required to compensate for
reduced first order depth.
3. Good control of tip and rotation due to wide
bracket 3. Reduced interbracket span; stiffer wire during level-
ing.
4. Unsuitable tip if canine requires mesialization
Swapped U1 bracket 1. Adequate palatal root torque 1. Labial enameloplasty is required
2. Suitable for moderate bodily mesialization 2. Labial offset bend may be required to compensate for
reduced first order depth.
OTT=ETT (+17˚/-4o) 3. Wide; good rotation & tip control during slid-
ing due to a reduced contact angle. 3. Reduced interbracket span; stiffer wire during level-
ing.
Ipsilateral U2 bracket 1. Moderate palatal root torque 1. Additional palatal root torque may be required
2. Adequate crown tip if no mesial movement is 2. Labial enameloplasty is required.
required.
OTT=ETT (+10˚/ +8˚) 3. Unsuitable if canine requires mesialization.
3. Adequate bracket offset
Swapped U2 bracket 1. Moderate palatal root torque 1. Additional palatal root torque may be required
OTT (+10˚/ +8˚) 2. Adequate crown tip if significant mesialization 2. Labial enameloplasty is required.
is required.
ETT (+10˚/ -8˚)
3. Adequate bracket offset
Inverted ipsilateral U3 1. Labial enameloplasty is not required before 1. Additional palatal root torque may be required
bracket bonding
2. Unsuitable for canine requiring mesialization.
OTT (-7o /+8o) 2. Adequate tip if no mesial movement is re-
quired.
ETT (+7o /+8o)
Inverted contralateral 1. Labial enameloplasty is not required before 1. Additional palatal root torque may be required
“swapped” U3 bracket bonding
OTT (-7o /+8o) 2. Adequate tip if significant mesial movement is
required.
ETT (+7o /-8o)
3. The integral hook can be used during mesial-
ization
Inverted ipsilateral U4/5 1. Labial enameloplasty is not required before 1. Additional palatal root torque may be required
bracket bonding.
2. Unsuitable tip for canine requiring mesialization or
OTT (-7˚/0˚) 2. The integral hook can be used during mesial- none.
ization
ETT (+7˚/0˚)
Ipsilateral L3 brackets 1. Labial enameloplasty is not required before 1. Additional palatal root torque may be required
bonding
OTT (-6˚/ +3˚) 2. Unsuitable for canine requiring significant mesializa-
2. Adequate tip if slight mesial movement is tion or none.
ETT (+6˚/-3˚)
required.
Contralteral L3 bracket 1. Labial enameloplasty is not required before 1. Additional palatal root torque may be required
bonding
OTT (-6˚/+3˚) 2. Unsuitable for canine requiring significant mesializa-
tion or none.
ETT (+6˚/+3˚)
HYPODONTIA 217
Ipsilateral L4s bracket 1. Moderate palatal root torque 1. Additional palatal root torque may be required
2. Adequate tip if slight mesial movement is 2. Unsuitable for canine requiring significant mesializa-
required. tion or none.
OTT (-12˚/+2˚)
3. Labial enameloplasty is not required before
ETT (+12˚/-2˚)
bonding
Inverted ipsilateral L4s 1. Adequate buccal root for intrusion cases 1. Excessive buccal root torque (risk of root resorption/
brackets fenestration) if premolar is not intruded.
2. Adequate tip if slight mesial movement is
OTT (-12˚/+2˚) required. 2. Insufficient tip if significant mesialisation is required
ETT (-12˚/-2˚)
Original Torque and Tip= OTT, Expressed Torque and Tip=ETT; the Torque and Tip is based on MBT prescription.
**In cases where a bracket with an integral hook is used and inverted, undesirable tipping may be expected during mesialization
because the point of force application is further away from the centre of resistance.
Associated side effects include increased tooth sensitivity, tute the lateral incisors. In this situation, the vertical posi-
regrowth of part of the excised gums, and gingival recession. tion of brackets should be such that after final reshaping,
Suppose the probing depth of the first premolar is normal in the substituted lateral incisors are 0.5 mm shorter than the
the presence of a thin gingival biotype. In that case, it is best substituted central incisors (McDowall et al., 2012).
to bond it more occlusal for intrusion and normalisation of • Compensated mesiodistal position of brackets for
gingival margins. Whereas in case of a low upper lip line or space closure treatment option: If both the canine
lack of gingival margin display, the canine bracket can also and premolar are to be relocated mesially, a slight
be bonded more gingival to bring its reduced incisal edge alteration in mesiodistal bracket position may be
0.5mm cervical to the central incisor’s edge, or normally necessary; this can be achieved through bonding the
if a composite build-up or veneer is planned for. The first be bonded at the same level as the second premolar
premolar should for a group functional occlusion. Another brackets more distally, especially for first premolars
clinical situation is when central incisors are missin g; lateral with divergent roots to prevent the buccal root from
incisors substitute the central incisors, and canines substi- moving into the cortical plate, which may slow down
218 HYPODONTIA
tooth movement and lead to periodontal breakdown tal dimension of the contralateral lateral incisor can also be
and root resorption. This off-set positioning of the used to determine the optimal size of the substituted laterals
premolar bracket also helps move its palatal cusp supplemented with Bolton’s equation and a diagnostic set-up.
distally, reducing cuspal interference and improving
E. Reopen or redistribute space
aesthetic outcomes. Moreover, the upper first molar
tube is positioned more distally to bring the mesial In summary:
cusp inwards for a solid Class II interdigitation if no
• cent teeth (Asher and Lewis, 1986).
extractions are planned in the lower arch.
• Consider retaining the primary teeth for preserving
Compensated axial tip of brackets for space closure treat-
alveolar bone for future placement of implants (Thi-
ment option
lander et al., 1994).
To achieve proper root parallelism at the agenesis site, the
• Before the advances in 3D printing and the use of
axial positions of the canine and premolar brackets may also
skeletal anchorage devices, space opening was rec-
be modified to produce geometry VI forces that allow appro-
ommended in (Paduano et al., 2014):
priate final root approximation.
HYPODONTIA 219
8. Cases with large canines. celain fused to metal bridges (PFB).
• The main disadvantage of space opening is the • The 5 and 10-year survival rate of resin-bonded
commitment of a dental prosthesis throughout life bridges (RBB) is 91% and 83%, respectively though
(Carter et al., 2003). RBBs with zirconia framework or that involving one
tooth showed the greatest survival rate (Thoma et al.,
• The benefits of space opening are:
2017).
1. Good interocclusal interdigitation can be achieved (Balshi,
• Survival of cantilevered RBB is at least as good as a
1993).
fixed design (Spear et al., 1997, Creugers et al., 1992,
2. Some suggest that the space opening approach is func- Hussey and Linden, 1996, Pröbsfer and Henrich,
tionally more stable and Ffaster treatment than space closure, 1997).
but with no string evidence.
• Survival rate of FRCB was 64% after 5 years, irre-
Space opening and prosthetic replacement spective of surface or hybrid retainer. Most failures
were due to fracture of the framework and delami-
Interim prosthesis of a space of a missing tooth
nation (van Heumen et al., 2009).
These include:
• Porcelain-fused-to-gold bridges have a favourable
• During treatment and once the required space has long-term survival rate of 68.3% after 20 years. Vi-
been achieved, a space maintainer such as an open tal teeth had about three times higher survival rates
coil spring or artificial denture tooth is attached to than endodontically treated teeth.
the orthodontic archwire. (Savarrio and McIntyre,
• The main reason for these failures was caries (30%)
2005).
(De Backer et al., 2008).
• Thermoplastic retainers or Hawley-type retainers
• Osseointegrated dental implants: If a dental implant
incorporating prosthetic teeth and wire stops should
is placed in the lateral incisor region, it should be
be used (Richardson and Russell, 2001).
placed in the correct restoratively determining 3D
• Removable partial dentures or bridges: They may be position (Yang et al., 2015).
the final long-term restoration if the patient chooses
Criteria for implant placement
not to have a dental implant in the long-term (Rada
et al., 2015). These include:
• Conventional porcelain fused to metal bridges: It • Mesial distal distance: At least 1.5 mm away from
is not recommended in young patients due to the the roots of adjacent teeth. Therefore, a minimum
large amount of tooth reduction required in teeth space of 6 mm mesiodistally is required for implants
with large pulps, so it is only placed after complete of 3.0 mm, as 1.5 mm space should be present on
growth. In young patients, the anterior spaces may either side of the dental implant (Kokich, 2004).
be closed and redistributed posteriorly for implant
• Vertical position: 2 and 3 mm (depending upon the
placement later; in the meanwhile, the posterior
design of the implant) apical to the anticipated gin-
space might be restored with interim bridges or
gival margin of the implant restoration.
bonded retainers (Kinzer and Kokich Jr, 2005).
• Labio-lingual position: At least 1.5 - 2 mm palatal
• Bonded orthodontic retainers, fixed resin bonded,
to the facial curvature of the arch, or point of emer-
or laboratory composite with fibre-reinforced bridg-
gence at the level of mucosal margin. A space of
es are recommended for longer interim periods to
1.5mm between the facial surface of the implant and
reduce root approximation.
the buccal cortex
• TADs supported prosthesis (Ciarlantini, 2019)
• Before debonding the fixed appliance, an appropri-
Types of final restorations ate measure of the inter-coronal/inter-radicular dis-
tances is essential.
1. Removable partial dentures: It is the restoration of choice
if the patient is unwilling to undergo lengthy and costly treat- Success of dental implants
ment.
A systematic review found success of dental implants after 5
2. Bridges years is 95.2%, and after 10yrs is 80%, though complications
occur in 24% of patients; mainly due to biological and techni-
• It includes adhesive or resin-bonded bridges (RBB),
cal factors (Pjetursson et al., 2012b). Clinical presentation of
fibre-reinforced composite bridges (FRCB) and por-
failed implants are:
220 HYPODONTIA
• Infraposition of single implant restorations Exam night review
• Peri-implant mucosal recession Hypodontia is the developmental absence of one or more
teeth, excluding third molars (Goodman et al., 1994). Also,
• Black triangles
known selective tooth agenesis (STHAG)
• Marginal bone loss around adjacent teeth and bone
Classification
loss buccally to the implants.
• Hypodontia
• Alteration of the contact point.
Agenesis of 1-6 teeth excluding third molars.
Treatment options for absent premolars
• Oligodontia
Treatment options depend on the amount of crowding:
Agenesis of more than six teeth, excluding the third molars.
• If the arch is spaced or aligned, preserve the de-
ciduous teeth, mainly deciduous second molars. If • Anodontia
the second deciduous molar survives until 20 years,
Complete absence of teeth.
they appear to have a good prognosis for long term
survival (Bjerklin and Bennett, 2000). If lower E is The candidate genes for non-syndromic hypodontia (Vas-
maintained, its mesiodistal width should be reduced tardis et al., 1996, Lammi et al., 2004, Cobourne, 2007b)
for optimum occlusion (premolarise). MSX1 and MSX2: MSX1 represents a candidate gene for
• In case of crowding, deciduous teeth should be ex- both syndromic and non-syndromic hypodontia.
tracted when appropriate. Extraction of upper E’s in • EDA.
Class II malocclusion and lower E’s in class 3 mal-
occlusion helps correct the overjet. For maximum • PAX9.
spontaneous space closure, consider extraction of • AXIN2
E’s at 9 years (Lindqvist, 1980). Consider controlled
sectioning of lower E’s to allow bodily space closure Incidence
(Hemi-sectioning). It has better success in patients Type of dentition: The incidence of hypodontia in decidu-
less than 9 yrs of age. (Valencia et al., 2004) ous teeth is 0.1-0.9 %. In permanent dentition 4-6% exclud-
Evidence summary ing third molars (Grahnén, 1956a).
• As per the systematic review and meta-analysis, Ethnicity variation: highest in Africa 13.4%, followed by
the prevalence of hypodontia is 6.4%, and it varies Europe 7%. Asian and Australians have the same prevalence
on different continents of the world. (Khalaf et al., of 6.3%. Gender variation: The incidence is 4.6% in males
2014) and 6.4% in females (Polder et al., 2004). Hypodontia is
more frequently reported in females.
• High chances of agenesis of lateral incisor in the
presence of peg laterals on contralateral side (Hua et Sequence of hypodontia: The common missing tooth types
al., 2013) in Caucasians are: lower second premolars > upper lateral
incisors > upper second premolars > lower central incisors
• Space closure is a better option if aesthetics allows (Larmour et al., 2005).
(Qadri et al., 2016, McNeill and Joondeph, 1973)
Third molars: These are the most commonly absent teeth
• Frequent debonding of resin-bonded bridges for with an incidence of 25-35% (Peck et al., 1996).
the replacement of missing teeth has been reported
(Thoma et al., 2017) Premolars: Premolars can form as late as 9 years of age.
Lower 5’s are the most commonly absent (2.6%), followed
• Failure of implant prosthesis can be reduced by con- by upper 5’s then 4’s (Wisth et al., 1974). Peck has reported
trolling biological and technical factors (Pjetursson a 3% incidence of missing second premolars (Peck et al.,
et al., 2012a). 1996).
Maxillary lateral incisors: Absent maxillary lateral incisors
constitute 2% of the population (Peck et al., 1996).
Lower incisors: Caucasians is 0.2% (J Neal and E Bowden,
1988).
Aetiology and theories of hypodontia
HYPODONTIA 221
• Evolutional theory: Decrease ins jaw size and tooth • Generalised spacing and rotation of teeth adjacent
number to the missing teeth
• Anatomical theory: Dental lamina in certain areas Complications/difficulties with treatment (Grahnén,
susceptible to environmental factors 1956b)
• Environmental theory: Chemotherapy, infections, • Anchorage difficulties
drugs, toxins, trauma, nutrition
• Atrophy and loss of bone
• Genetic factors: Polygenic multifactorial
• Root parallelism for implants
Features of malocclusion
• Aesthetics
Skeletal features (depending on the severity of malocclusion)
• Risk of relapse, e.g. spaces reopening
• Retrognathic and hypoplastic maxilla (Wisth et al.,
• Cost of treatment
1974, Hobkirk et al., 1995).
• Treatment time may be increased
• Small MMPA and reduced vertical dimensions.
(Taju et al., 2018). • Treatment outcome may be compromised
• Low mandibular plane angle is associated with re- • Common issues faced in treating these patients in-
duced lower anterior facial height and protrusive clude: space management, uprighting and aligning
lips (Chung et al., 2000). teeth, management of the deep overbite, and reten-
tion (Carter et al., 2003).
Alveolar features
Treatment factors (Hobkirk et al., 1995)
• Lack of alveolar bone
• Age.
• There is often a fairly flat palatal vault, resulting in
reduced anchorage capacity of upper removable ap- • Medical history.
pliances, Nance palatal arch, or implant placement. • Patient’s opinion and co-operation.
Occlusal features (Fekonja, 2005b) • Facial profile.
• Upright incisors. • Smile line.
• Over-erupted incisors. • Gingival line.
• Increased overbite • Malocclusion and extent of hypodontia.
Dental features • Intra- and inter-arch relationships
• Delayed and asymmetric eruption of permanent • Dental features size, shape, the colour of the adja-
teeth. cent teeth.
• Prolonged retention of primary teeth (Kurol and • Clinical situation of retained teeth.
Thilander, 1984).
Sequence of treatment (Spear et al., 1997)
• Infra-occlusion of primary teeth (Kurol and Thilan-
der, 1984). • Create a diagnostic set-up and Kesling set-up.
• Ectopic eruption or impaction of the adjacent teeth, • Determine the sequence of orthodontic treatment.
particularly maxillary canines. • Building-up malformed teeth and answering the
• Microdontia (Graber, 1978) following questions:
• Conical crown. (Brook, 1984) • Where should the maxillary lateral incisor (U2) be
positioned mesiodistally
• Transposition (Peck et al., 1996)
• Where should U2 be positioned buccolingual:
• Enamel hypoplasia.
• Where should U2 be positioned inciso-gingivally?
• Molar taurodontism
• Evaluate gingival aesthetic.
• Short roots
• Determine space required by golden proportion,
• Enamel hypoplasia universal mesiodistal width, contra-lateral tooth size
222 HYPODONTIA
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226 HYPODONTIA
Supernumerary Teeth
22
Written by: Mohammed Almuzian, Haris Khan, Eesha Najam, Lubna Almuzian , Abbas Naseem
In this Chapter
1. Incidence of supernumerary teeth
2. Aetiology of supernumerary teeth
3. Genetic influences
4. Clinical features of supernumerary
teeth
5. Classification of supernumerary teeth
6. Examination of supernumerary tooth
7. Management of supernumerary tooth
8. Detailed management of each type of supernu
merary
9. The recommendations of the Royal College of
Surgeon of England
10. Evidence summary
11. EXAM NIGHT REVIEW
• Supernumerary teeth are 5-10 times more common • Local, independent or conditioned hyperactivity of
in the maxilla than in the mandible (Alvira-Gonza- dental lamina: Supernumerary can also result from
lez and Gay-Escoda, Ata-Ali et al., 2014, Scheiner disturbances during the initiation and proliferation
and Sampson, 1997). stages of dental development and, like tooth agen-
esis, can occur as part of a larger disease process,
• The incidence of supernumerary teeth in primary syndrome or as an idiopathic finding. (Proffit et al.,
dentition is 0.06% to 0.8% (Cobourne et al., 2012, 2018).
Brook, 1974).
Genetic influences in the development of supernumerary
• Supernumerary in the primary dentition is often fol- teeth
lowed by a supernumerary in the permanent denti-
tion (Littlewood and Mitchell, 2019, Lu et al., 2017). Genetic influence can be appreciated by the fact that:
• The incidence of supernumerary teeth in the perma- • 20.5% of patient also had first-degree relatives with
nent dentition in the Caucasian population is 1-2% a supernumerary teeth (McBeain and Miloro, 2018),
(Garvey et al., 1999, Shah et al., 2008) of which 80 • Association with specific medical and dental disor-
% are present in the anterior maxilla, mostly in the ders (Rajab and Hamdan, 2002),
central incisor region 51.2% (Di Biase, 1969, Mc-
Beain and Miloro, 2018). • Ethnic variations,
• Supernumerary teeth in the premolar and molar re- • Sexual dimorphism (Rajab and Hamdan, 2002)
gions occur at the incidence of 10% of all supernu- Following patterns of inheritance may be observed: (Fleming
merary cases (Hyun et al., 2008). et al., 2010)
• Supernumerary teeth can be presented unilater- • Autosomal dominant with incomplete penetrance
ally or bilaterally and can occur individually or in
groups. A meta-analysis found bilateral occurrence • Sex linked trait
more common in non-syndromic multiple super- • Autosomal recessive trait with lesser penetrance in
numerary teeth (Alvira-Gonzalez and Gay-Escoda, females
2012) however, multiple supernumerary teeth could
Table 1: Syndromes associated with supernumerary teeth
be an indicator of an underlying medical disorder
(Subasioglu et al., 2015). Syndrome
• Supernumerary teeth can occur either as an isolated Cleft lip and palate
trait or as a manifestation of a clinical syndrome
Cleidocranial dyplasia (gene RUNX2)
(Shah et al., 2008) Table 1
Gardner syndrome (gene APC)
• In the CLP cases, the prevalence of supernumeraries
Ellis–van Creveld (gene EVC; EVC2)
is as high as 1.9 to 10%, due to the disruption of the
dental lamina during cleft formation. (Akcam et al., Incontinentia pigmenti (gene NEMO)
2010). Down’s syndrome and its association with Cleft lip and pal-
ate
Aetiology of supernumerary teeth
Ehlers-Danlos syndrome
Different theories have been suggested for the aetiology of su-
pernumerary teeth (Garvey et al., 1999). These are:
23
Written by: Mohammed Almuzian, Haris Khan, Abbas Naseem, Lubna Almuzian
In this Chapter
1. Incidence of unerupted central incisor 16. Advantage of autotransplantation
2. Aetiology of unerupted central incisor 17. Risks and disadvantage of autotransplantation
3. Effects of unerupted central incisor 18. Factors effecting success of autotransplantation
4. Diagnosis of unerupted central incisor 19. Success rate of autotransplantation
5. Considerations during treatment planning 20. Prognosis of autotransplantation
6. The correlation between dilacerated and impac 21. Management of ankylosed maxillary incisors
tion of incisors 22. Evidence summary
7. Types of tooth dilacerations 23. EXAM NIGHT REVIEW
8. Methods for space creation to allow spontane
ous eruption
9. Extraction/removal of physical obstruction
10. Watchful waiting or mechanical traction?
11. Open surgical exposure techniques
12. Closed surgical exposure techniques
13. Open versus closed exposure techniques
14. Surgical extraction and coronectomy
15. Auto-transplantation
D elayed eruption of permanent maxillary incisors can be
• Gingival fibromatosis.
According to Becker, the aetiology of impacted maxillary
defined if any of the following conditions are met (Seehra et
al., 2018a): central incisors can also be divided into obstructive or trau-
matic causes (Becker, 2013):
• The contralateral maxillary central incisor is delayed
by more than 6 months A. Obstructive causes
Surgical extraction of the impacted incisor and coronec- 1. Root development and status such as:
tomy • 1/3rd to 2/3rd of the root of the donor’s teeth should
Extraction and coronectomy of unerupted incisor can be be formed. If the root development of donor’s teeth
considered in the presence of: is more significant than 3/4rd, the root canal of the
teeth should be done within 10 days of transplanta-
• Severe dilaceration or coronal dilaceration tion.
• Ankylosis • Atraumatic extraction of donor’s teeth
• Severe infra-occlusion • Intact periodontium of the donor’s tooth
• Space closure in the mixed dentition, followed by • Minimum invasive surgery for an impacted tooth
space reopening in the permanent dentition to gain removal.
bone volume
2. Post-transplantation splinting and stabilisation: After
Surgical extraction or auto-transplantation transplantation, splinting of the transplanted teeth for 7-14
Autotransplantation helps preserve the bone at the extraction days using bonded flexible wire is essential. Splinting can also
side and stimulate bone growth by the eruption of the trans- be done with orthodontic brackets if other malocclusion fea-
planted tooth. tures need to be corrected, but appliances should be passive
on the transplanted tooth. If orthodontic brackets are bonded
Autotransplantation of premolars is a viable method for re- for splinting, there should be enough gap between the gingiva
placing maxillary central incisors with an excellent long-term and bracket, so the patient can easily clean the area above the
survival (Stange et al., 2016). Ideally, the lower second pre- bracket.
molar can be auto-transplanted at the upper central incisors
position where extractions of the lower arch are indicated for Success rate of autotransplantation
orthodontic reasons (Kvint et al., 2010). Premolars should be The success rate for premolar transplant has been reported
rotated by 90° to increase the mesiodistal width and improve from 81-98% (Kvint et al., 2010, Kristerson and Lagerstrom,
gingival aesthetics. 1991, Czochrowska et al., 2000, Andreasen et al., 1990). Only
Advantages of autotransplantation one study reported a 100% success rate, but only four premo-
lar cases were included in the study (Slagsvold and Bjercke,
24
Written by: Mohammed Almuzian, Haris Khan,Maham Munir, Abbas Naseem
In this Chapter
1. Prevalence and Incidence 17. Type of surgical exposure
2. Development and eruption of maxillary canines 18. Mechanical eruption of the impacted canine
3. Aetiology of impacted canines 19. Indications for surgical removal
4. Recent classification 20. Indication of transalveolar autotransplant
5. Theories of palatally impacted canines 21. Indication of surgical repositioning
6. Classification of impacted maxillary canines 22. Causes of poor outcome
7. Consequences of an impacted canine 23. Impacted mandibular canine
8. Investigations and diagnosis 24. EXAM NIGHT REVIEW
9. Magnification technique
10. Parallax Technique
11. Sectors classification
12. Risk factors for resorption of lateral roots
13. Management and treatment
14. Interceptive treatment
15. Guidelines for interceptive treatment
16. Surgical exposure and orthodontic alignment
A canine is considered impacted if: canine erupts into position, the physiological median dia-
stema closes (Becker, 1978). The maxillary canine should be
• It is unerupted after three quarters root develop- palpable in the buccal sulcus by the age of 10 years (Ferguson,
ment (Litsas and Acar, 2011). 1990).
• The contralateral tooth has erupted for at least 6 In general, maxillary canines erupt earlier in females than
months with complete root formation or in males (Wedl et al., 2004) usually at the age of 11-12 years
while the mandibular canine erupts at the age of 10-11 years
• The canine position is intraosseous at or beyond CS5 (Littlewood and Mitchell, 2019) (Brin et al., 1986b). It has
or 2 years after adolescent growth spurt or 6 month been suggested that ectopic canines are associated with de-
after its root completion (Lindauer et al., 1992). layed dental development (Becker and Chaushu, 2000).
Ectopic or displaced canines (DCs) refers to intraosseous Aetiology of impacted canines
or infraosseous position of the canine before the expect-
ed time of the eruption. The aetiology of impacted canines is multifactorial, both envi-
ronmental and genetic factors are purposed for this anomaly.
Prevalence and Incidence
• Path of eruption: The long tortuous path of eruption
In summary: of upper canine, which is about 22mm, increases the
• Maxillary canines are developmentally absent in probability of impaction. Some experts (absence of
0.3% of the population (Brin et al., 1986a). strong evidence) stated that impacted canines are
more common in patient with long face.
• Mandibular canines are developmentally absent in
0.1% of the population (Littlewood and Mitchell, • Obstruction of the path of eruption: Deciduous ca-
2019) nines can be slightly resistant to resorption prevent-
ing the eruption of permanent canines. The presence
• Maxillary canines are second most frequently im- of supernumerary teeth, cyst, fibrous tissue or dense
pacted teeth after mandibular third molar. bone can also obstruct the eruption of the canine
• Impacted canine has incidence of 1.7 to 2% (Ericson leading to impaction.
and Kurol, 1988a, Ericson and Kurol, 1986b). • Arch length discrepancy: Crowding or shortening
• Palatal impaction of canine is the most common of the length of the arch can lead to buccal impac-
61%, followed by the impaction within the line of tion (Jacoby, 1983). Also, in buccal impacted ca-
the arch 34%. While buccal impaction contributes nines, there is usually reduced maxillary intercanine
to 4.5% of the total canine impactions (Stivaros and width and hyperdivergent skeletal relationships.
Mandall, 2000). • Dental anomalies and canine guidance: The canine,
• Unilateral impactions are 4 times more frequent during its eruption takes guidance from the roots of
than bilateral impactions of the canines. lateral incisors. Maxillary lateral incisor anomalies
such as ectopic eruption/ inclination and hypodon-
• Female to male ratio is 7:3 (Mossey et al., 1994). tia or microdontia increases the chances of deviation
• Dachi and Howell (Dachi and Howell, 1961) showed of the canine from its path. A study found that the
that the majority of impacted maxillary canines are incidence of canine impaction is increased to 42.6%
unilateral (92%), and only 8% are bilateral while the if lateral incisors are small or developmentally ab-
female to male ratio is 2:1. sent (Brin et al., 1986b).
• Impacted canines are more frequent in in Class II • Genetic background: Palatal impactions are mostly
div.2 malocclusion (Mossey et al., 1994). due to genetic reasons, this is why it is more com-
mon among some ethnic patient’s, females, twins
Development and eruption of maxillary canines and in certain families (Jacobs, 1996).
The calcification of the canine commences at 4-5 months and Recent classification of aetiology of maxillary canine im-
completes at 5−6 years of age. Canine development occurs paction
at high level in the maxilla, lateral to the piriform fossa, and
has the longest path of eruption (22 mm). Canine migrates These include (Becker and Chaushu, 2015):
forward and downwards to lie buccal and mesial to the apex 1. Local hard tissue obstruction
of the deciduous canine, then continues to move down and
mesially pushes the distal aspect of the root of the upper lat- • Lappin’s theory of over-retained deciduous canine
eral incisor creating a physiological median diastema. As the • Supernumerary teeth and odontoma
• Good aesthetic The surgical site is then closed with mono-nylon 6.0 sutures.
After the impacted canine is sufficiently exposed, the chain is
• No mucosal bunching removed, and orthodontic traction of the canine is initiated
Disadvantages of closed exposure (Bariani et al., 2017).
25
Written by: Mohammed Almuzian, Haris Khan, Ahmed El-Shanawany, Maha Urooj, Abbas Naseem
In this Chapter
1. Classification of failure of eruption
2. Incidence of PFE
3. Aetiology of PFE
4. Features of PFE
5. Treatment options of the PFE
6. Aetiology of the mechanical failure of eruption
7. EXAM NIGHT REVIEW
P rimary failure of eruption (PFE) is defined as the failure of
• Positive family history of gene mutation. PFE is con-
sidered an idiopathic non-syndromic autosomal-
a permanent tooth to erupt in the absence of any mechanical dominant condition (Decker et al., 2008).
obstruction or systemic condition (OMIM 125350) (Proffit
and Vig, 1981). PFE is attributed to a disturbance in the erup- Features of PFE
tion mechanism, which results in complete failure of erup- These include:
tion (primary retention PFE) or partial failure of eruption
• Affected teeth are infra-occluded.
(secondary retention PFE) of a non-ankylosed tooth (Rhoads
et al., 2013). • Posterior open bite, however, average vertical pro-
portions.
Classification of failure of eruption
• Affected teeth are non-responsive to orthodontic
These include (Frazier-Bowers et al., 2007):
traction after slight movement; affected teeth be-
1. Primary failure of eruption which is subdivided into two come ankylosed.
types, depending on the clinical gradient of the open bite se-
• In PFE, the first permanent molars are constantly
verity:
involved with an increased second molar and second
• Type 1: Progressive anterior to posterior lateral open premolar involvement (Rhoads et al., 2013).
bite with lack of all involved teeth eruption poten-
• Teeth distally present to the affected tooth are usu-
tial. Type 1 appears to occur at a certain chronologi-
ally involved.
cal age.
• Affected teeth have a supracrestal presentation.
• Type 2: Teeth distal to the affected tooth have a
smaller lateral open bite but still inadequate erup- • Other dental anomalies can also be present.
tion. Type 2 correlates to the root developmental
• Radiographic features of ankylosis. It is essential to
stage.
notice that the sensitivity in diagnosing ankylosis
2. Secondary failure of eruption is an unexplained cessation is 60-70% with CBCT and 30-50% with OPG. This
in eruption after the tooth has penetrated the gingiva into the means that the chance of false-positive results with
oral cavity (Raghoebar et al., 1991a, Raghoebar et al., 1991b). OPG is almost 1 in 2 while 1 in 3 with the CBCT
(Ducommun et al., 2017).
3. Mechanical failure of eruption (Schätzle et al.) due to ob-
structed path of eruption with an apparent obstruction. Treatment options of the PFEc
4. Intermediate failure of eruption (IFE): Unclear if PFE or These include:
MFE due to the patient being too young to diagnose.
• No treatment for mild cases
Incidence of PFE
• Segmental osteotomy includes corticotomy and seg-
In summary: ment distraction to extrude the affected tooth and
alveolar bone to erupt. Some recommend using an
• The incidence of PFE is 0.6% (Frazier-Bowers et al.,
orthodontic bone stretching (Bousquet et al., 2016).
2016).
• Restoration of the occlusal table: This may involve
• Familial predilection in PFE is found in 10% - 40%
composite build-ups, prosthetic crowns, bridgework
of cases with females and permanent molars most
or extraction and implants placement. Restoration of
affected (Rhoads et al., 2013, Ahmad et al., 2006).
occlusion need a multi-disciplinary approach, and a
• PFE is usually found in Class 3 malocclusion cases. definite treatment plan is based on several erupted
• There is no difference between maxillary and man- teeth and the vertical functional occlusal height to
dibular involvement for PFE. be restored (Rhoads et al., 2013).
•
PFE mainly occur bilaterally, affecting multiple Aetiology of the mechanical failure of eruption
teeth. These include:
Aetiology of PFE 1. Local factors due to mucosal barrier such as supernumer-
These include: ary or arch length deficiency as well as severe trauma
26
Written by: Mohammed Almuzian, Haris Khan, Abbas Naseem, Muhammad Qasim Saeed
In this Chapter
1. Types of transposition
2. Aetiology of transposition
3. Prevalence of transposition
4. Classification of transposition
5. Treatment planning consideration
6. Maxillary canine and the first premolar
7. Maxillary canine-lateral incisor transposition
8. Maxillary canine-first molar transposition
9. Maxillary incisors transposition
10. Maxillary canine central incisor transposition
11. Mandibular canine lateral incisor transposition
12. Mandibular canine central incisor transposition
13. Intraosseous migration
14. Clinical signs of intraosseous migration
15. Classification of intraosseous migration
16. EXAM NIGHT REVIEW
T ooth transposition is the positional interchange of two
the upper arch (Peck and Peck, 1995) are:
• Canine–first premolar (Mx.C.P1).
adjacent teeth or the eruption of a tooth in a position usu-
ally occupied by a nonadjacent tooth. Transposition is also • Canine–lateral incisor (Mx.C.I2).
known as ‘Transversion’ (Lischer, 1912).
• Canine on the site of first molar (Mx.C.M1).
Types of transposition
• Lateral incisor–central incisor (Mx.I2.I1).
These include:
• Canine on the site of the central incisor (Mx.IC.I1).
• Complete transposition or true transposition in
While the commonest types of transposition which are found
which both the crown and roots of adjacent teeth
in the lower arch are (Aydin et al., 2004):
are completely transposed (Shapira and Kuftinec,
1989b). • Mandibular lateral incisor-canine transposition (Mn.
I2.C).
• Incomplete or pseudo-or partial transposition in-
volves interchange in the positions of adjacent • Mandibular canine transmigrated/erupted (Mn.C. tran-
crowns only, with the roots remaining in their cor- serupted).
rect position (Shapira and Kuftinec, 1989b).
Maxillary canine and the first premolar (Mx.C.P1) (Pair,
Aetiology of transposition 2011, Peck et al., 1993)
These include: The overall prevalence of Mx.C.P1 is 55%-70%. Bilateral oc-
currence occur in 27% of the cases. The familial occurrence is
•
Multifactorial, both genetic and environmental
11% while the male to female ratio is 1:1.55. The clinical signs
components are involved (Shapira and Kuftinec,
of of Mx.C.P1 (Filhoa et al., 2007) are:
1989b, Peck et al., 1993).
• Canine is usually displaced between the first and
• Strong association with tooth agenesis and peg-
second premolars in a mesiobuccal direction.
shaped upper lateral incisor teeth.
• First premolar is frequently distally tipped and dis-
Prevalence of transposition
placed in a mesio-palatal direction.
According to a meta-analysis, the overall prevalence of trans-
• The primary canine is often present, creating local-
position is 0.33% (Papadopoulos et al., 2010). transposition
ised crowding.
mostly affecting upper teeth, 68.5%-76% (Papadopoulos et
al., 2010). Canines are involved in 90% of transposition cases Treatment options of of Mx.C.P1 are:
(Ely et al., 2006b), mostly (88%) unilateral (Ely et al., 2006a).
1. Interceptive treatment (Peck and Peck, 1995): This in-
There is left-sided dominance of transposition though trans-
volves the extraction of the retained primary tooth between
position has never been reported in both arches simultane-
six and eight years of age. Interceptive treatment can be ad-
ously (Shapira and Kuftinec, 1989a) or in deciduous dentition.
opted before transposition is complete, usually around 10
Some studies reported female predilection of transposition
years of age.
though a meta-analysis reported no specific gender predilec-
tion (Papadopoulos et al., 2010). 2. Definitive treatment such as (Shapira and Kuftinec,
1989a):
Classification
• Accepting the transposition.
Three-part coding was purposed to classify transpositions
(Favot et al., 1986, Peck and Peck, 1995) including: • Extraction of one of the transposed teeth followed
by orthodontic alignment after opting for either ac-
• Part 1: Jaw of occurrence, coded as either Mx = Maxilla
cepting or correcting the transposition (Filhoa et al.,
or Mn = Mandible.
2007).
• Part 2: Transposed tooth, coded as - I1 = central incisor,
• Correcting the transposition: When repositioning
I2 = lateral incisor, C = canine, P1 = first premolar, P2 =
the transposed teeth, care should be taken to avoid
second premolar, M1 = first molar, M2 = second molar.
occlusal interference and root resorption, as well as
• Part 3: Site of transposition, same coding as part 2. bone loss of the buccal bone plate. The palatally dis-
placed premolar should be initially moved palatally
Example: Mx.C.P1 represents transposition of the maxillary
‘palatal parking’ to allow unrestricted buccal move-
canine to the first premolar position.
ment of the canine toward its normal position. Af-
The five common types of transpositions which are found in ter repositioning the canine, the premolar may be
27
impaction
Written by: Mohammed Almuzian, Haris Khan, Muhammad Qasim Saeed
In this Chapter
1. Prevalence of third molar impaction and hy
podontia
2. Aetiology of third molar impaction
3. Classification of third molar impaction
4. Lower incisor crowding and third molar debate
5. Research recommendations
6. EXAM NIGHT REVIEW
T ooth impaction is a tooth whose root is developed more
ond molar’s cervical margin.
C. According to the inclination of the long axis of the third
than three-quarters of the final root length and whose spon-
taneous eruption is not expected in a reasonable time in its molar about the long axis of the second molar
normal functional position due to the bone, tooth, or fibrous • Vertical Impaction
tissue considered to be an impacted tooth.
• Horizontal impaction
Prevalence of third molar impaction and hypodontia
• Mesio-angular impaction
Third molars hypodontia are common among more females;
• Disto-angular impaction
the females to males ratio are 3:2 (Richardson, 1979). Third
molars impaction is the most among all the teeth. An inci- • Inverted impaction
dence of 16.7% to 68.6%% has been reported in the literature
Lower incisor crowding and third molar debate
(Hashemipour et al., 2013; Bishara and Andreasen, 1983).
Studies relating third molars impaction to lower incisors
Aetiology of third molar impaction
crowding. Bergstrom and Jensen’s study (Bergstrom, 1960)
These include: found a greater degree of crowding in both maxilla and
mandible on the side where the third molar was present.
• Systemic causes include endocranial dysfunction,
Richardson and Mills(Richardson and Mills, 1990) sug-
developmental diseases and genetic disorders such
gested that the presence of a developing third molar can, in
as cleidocranial dysostosis and cleft lip/ palate.
some cases, cause forward movement of buccal teeth with an
• Local causes such as lack of space due to macordon- increase in crowding. They proposed that the second molar
tia or under-development mandible (micrognathia), extraction effectively reduces the incidence of late lower arch
the excessive density of the bone or the soft tissues crowding.
overlying the tooth and ectopic position of the third
Studies refute the relationship between third molars impac-
molars.
tion and lower incisors crowding. Ades and Harradine (Ades
Classification of third molar impaction et al., 1990; Harradine et al., 1998) found a lack of corre-
These include: lation between third molars and crowding. In their ran-
domised clinical trial, Harradine and team Field (Harradine
et al., 1998) concluded that the removal of third molars in an
A. According to the available space between the distal attempt to reduce the degree of late lower incisor crowding
surface of the second molar and the anterior border of the could not be justified.
ascending ramus of the mandible Research recommendations
• Class I: There is sufficient space to accommodate the Bishara and Andreasen recommendations: Bishara and An-
mesiodistal diameter of the crown of the third mo- dreasen (Bishara and Andreasen, 1983) suggest that if only
lar. the mandibular premolars are either missing or extracted,
• Class II: There is insufficient space to accommodate the lower third molar will, in the end, contact the upper 2nd
the entire mesiodistal dimension, i.e., part of the molar and prevent the over-eruption of the upper 3rd molar,
crown of the lower third molar is located within the hence, lower third molar extraction should be avoided in
ramus. these cases for ideal occlusion. Extraction of the third molar
should be avoided in cases with first and second molars of
• Class III: There is no space for the third molar to poor prognosis, particularly in non-growing persons with
erupt, i.e. the whole crown of the third molar is lo- Class II malocclusion or open-bite tendencies.
cated within the ramus.
National Institute of Dental Research in 1979 and the
B. According to the relative depth of the tooth within the American Association of Oral and Maxillofacial Surgery in
bony mandible 1993 recommendation: There is no evidence to suggest that
• Position A: The highest point of the tooth is at or a third molar is needed to develop the basal skeletal compo-
above the occlusal plane level of the adjacent tooth. nents of the maxilla and mandible. For cases involving dis-
talization, third molar extraction can be considered. There is
• Position B: The highest point of the tooth is below little rationale for extracting the lower third solely to avoid
the occlusal plane of the adjacent tooth but above future lower incisor crowding. If adequate room is available
the cervical margin of the adjacent tooth. for a third molar eruption, every effort should be made to
Position C: The highest point of the tooth is below the sec- bring these teeth into functional occlusion. If extraction of
third molars is indicated, it is preferable not to perform an